THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT 


r,   and  Mrs,    'jI,   Libby 


w 


RHEUMATISM, 

RHEUMATIC  GOUT,  AND  SCIATICA 


"  RHEUMATISMUS  SI  MINUS  PERITE  TRACTETUR,  NON  AD 
MENSES  TANTUM,  SED  AD  ANNOS  ETIAM  ALIQUOT,  IMMO  PER 
OMNEM  ADEO  VITAM,  MISERUM  HAUD  INFREQUENTER  DIS- 
CRUCIAT." 

Sydenhami  Opera,  Cap.  V,  sect.  vi. 


ON 


RHEUMATISM, 


EHEUMATIC  GOUT,  AND  SCIATICA, 


PATHOLOGY,  SYMPTOMS,  AND  TREATMENT. 


HENRY  WILLIAM  FULLER,  M.D.  Cantab., 

FELLOW   OF  THE    ROYAL   COLLEGE   OF   PHTSIOIANS,   LONDON  j     PHYSICIAN   TO   ST.    GEORGE'i 
HOSPITAL,    ETC.,    ETC. 


Jtom  the  ta;st  l^ondon  ©ditioit. 


PHILADELPHIA: 
LINDSAY    &    BLAKISTON 

1864. 


IIKNUY    n.    ASIIMEAD.    PRINTER, 


W£ 


PREFACE  TO  THE  THIRD  EDITION. 


The  demand  which  has  arisen  for  a  Third  Edition  of 
this  Treatise  induces  me  to  hope  that  my  researches  into 
the  nature  of  Rheumatism  and  Rheumatic  Gout,  and  my 
efforts  to  introduce  a  successful  method  of  treatment  have 
not  been  wholly  unavailing.  Encouraged  by  this  feeling, 
I  have  endeavored  to  render  the  work  as  complete  and 
useful  as  possible,  by  bestowing  more  than  ordinary  care 
on  its  revision,  by  adding  many  practical  suggestions,  and 
by  carefully  recording  the  result  of  my  experience  as 
to  the  action  of  remedies  which  have  been  recently 
introduced. 

The  time  which  has  elapsed  since  I  first  broached  my 
opinions  on  the  subject  of  Acute  Rheumatism  has  enabled 
me  to  estimate  at  its  true  value  the  method  of  treatment 
which  I  then  proposed ;  and  I  have  much  satisfaction  in 
being  enabled  to  affirm  that  the  statements  formerly 
made  as  to  its  efficacy  have  been  more  than  verified.  It 
subdues  the  pain  and  inflammation  within  a  few^  days, 
and  if  vigorously  carried  out,  completely  protects  the 
heart  from  mischief. 

My  views  as  to  the  nature  of  Rheumatic  Gout,  and  its 


vl  PREFACE. 

entire  independence  of  Gout  and  Rheumatism,  have  re- 
ceived confirmation  from  the  published  researches  of 
Adams,  Garrod,  and  others,  and  it  only  remains  for  me 
to  state  that  extended  observation  has  led  me  to  believe 
that,  if  properly  managed,  this  disease  is  far  less  obsti- 
nate and  formidable  than  it  has  appeared  to  be  under  the 
ordinary  methods  of  treatment. 

On  the  subject  of  Chronic  Rheumatism,  much  still 
remains  to  be  ascertained ;  for  I  am  satisfied  that  many 
maladies  are  included  under  that  comprehensive  title 
which  have  nothing  more  in  common  than  have  small- 
pox and  chicken-pox.  I  have  endeavored,  however,  as 
far  as  possible,  to  separate  the  different  varieties,  and  to 
point  out  the  remedies  to  which  each  is  most  amenable. 

In  the  chapter  on  Sciatica  and  Neuralgic  Rheumatism, 
I  have  given  the  result  of  my  experience  as  to  the  effect 
of  injecting  morphia  into  the  cellular  tissue,  and  have  also 
specified  the  conditions  under  which  galvanism,  elec- 
tricity, and  other  remedies,  prove  useful.  I  have  also 
appended  a  few  cases  illustrative  of  the  treatment 
recommended. 

My  friends  have  urged  me  to  add  a  chapter  on  Gout, 
as  being  an  important  member  of  the  family  of  diseases 
comprehended  in  the  scope  of  the  present  inquiry.  But 
it  would  add  so  greatly  to  the  bulk  of  this  book,  that  I 
have  determined  to  reserve  my  remarks  on  the  subject 
for  a  separate  volume. 


PREFACE  TO  THE  FIRST  EDITION. 


Above  two  thousand  years  ago,  Hippocrates  laid  down 
the  maxim,  that  all  theories  should  be  framed  xara  f^vsw 
Siuf^Mv.  From  that  time  to  the  present,  this  maxim  has 
prevailed  in  many  departments  of  medical  science ;  but 
in  the  investigation  of  rheumatism  it  has  been  too  often 
neglected.  Cold,  and  inflammation  consequent  thereon, 
have  been  regarded  as  the  beginning  and  end  of  the 
disease ;  and  any  facts  militating  against  this  doctrine 
have  been  heedlessly  passed  by  or  pronounced  of  little 
moment.  So  that,  in  the  words  of  Professor  Whewell, 
"the  subjects  of  attention  have  not  been  external  objects, 
but  speculations  previously  delivered ;  the  object  has  not 
been  to  interpret  nature,  but  man's  mind ;  the  opinions 
of  the  masters  are  the  facts  which  the  disciples  have 
endeavored  to  reduce  to  unity,  or  to  follow  into  con- 
sequences."^ 

With  the  view  of  avoiding  this  source  of  error,  I  had 
proposed  to  myself  to  commence  the  present  Treatise  by 
a  faithful  record  of  all  that  has  been  ascertained  of  the 
history  of  rheumatism ;   and  by  reference  to  the  facts 

^  Whewell's  "  Inductive  Sciences,"  vol.  i,  p.  18. 


Viil  PREFACE. 

thus  proved  and  established,  to  show  how  conflicting  opin- 
ions may  be  reconciled,  and  the  pathology  and  treatment 
of  the  disease  elucidated.  The  reader  would  thus  have 
been  impressed  at  the  outset  with  many  of  those  striking 
facts  which  serve  as  exponents  of  the  true  nature  of  the 
disorder,  and  would  have  been  enabled  to  estimate  the 
force  of  any  argument  opposed  to  his  preconceived  opin- 
ions. But  so  many  obstacles  presented  themselves  to 
this  arrangement,  that  I  determined  to  commence  at  once, 
by  a  full  exposition  of  my  views  of  the  disorder,  and  by 
constant  reference  to  established  facts,  to  counteract,  as 
far  as  possible,  those  sources  of  uncertainty  which,  under 
this  arrangement,  might  otherwise  have  presented  them- 
selves. Nothing  but  a  firm  conviction  of  the  necessity 
for  a  full  recognition  of  the  true  nature  of  the  disease, 
with  a  view  to  its  scientific  and  successful  treatment, 
could  have  induced  me  to  enter  so  fully  as  I  have  done 
into  the  various  circumstances  which  bear  upon  this 
important  question  ;  and  if  such  details  appear  out  of 
place  in  a  treatise  intended  to  be  purely  practical,  their 
insertion  will,  I  trust,  be  excused,  on  account  of  the 
information  they  allbrd  to  the  Physiologist. 

The  space  allotted  to  those  diseases  of  the  Heart  which 
arise  so  frequently  in  connection  with  Rheumatism,  may, 
at  first  sight,  appear  unnecessarily  large.  But  the  im- 
portance of  these  affections  cannot  be  over-estimated. 
They  may  complicate  and  render  formidable  the  simplest 
case  of  Rheumatism,  and  may  affect  the  future  as  well 


PREFACE.  IX 

as  the  present  safety  of  the  patient ;  moreover,  they  are 
the  very  points  on  which  the  Student  is  most  in  need  of 
instruction  and  advice.  Their  incursion  is  often  insidious, 
their  progress  rapid  ;  and  he  who  is  not  well  informed  on 
all  that  relates  to  their  symptoms  and  treatment,  may 
often  overlook  their  existence,  and  fail  to  avert  their  most 
dangerous  consequences.  I  have  therefore  been  unwilling 
to  omit  anything  which  may  lead  to  a  just  estimate  of 
their  importance,  to  a  full  understanding  of  their  physical 
signs  and  symptoms,  and  to  a  due  appreciation  of  the 
various  grounds  on  which  their  treatment  should  be 
based. 

I  have  availed  myself  of  the  labors  of  my  predecessors, 
wherever  their  views  have  appeared  to  me  correct ;  and 
have  uniformly  acknowledged  the  source  and  extent  of 
my  obligation.  Where,  as  on  some  points,  I  differ  from 
those  for  whose  judgment  and  experience  I  have  the 
greatest  regard,  I  have  not  hesitated  to  avow  it,  and  to 
point  out  the  grounds  of  my  opinion.  In  so  doing,  I  have 
strictly  adhered  to  facts,  and  believe  I  have  stated 
nothing  which  will  not  be  confirmed  hy  more  extended 
inquiries. 

To  my  colleague  and  former  teacher.  Dr.  J.  A.  Wilson, 
Senior  Physician  to  St.  George's  Hospital,  I  am  indebted 
for  having  first  awakened  my  mind  to  the  necessity  for 
a  complete  and  searching  investigation  into  the  source, 
nature,  and  treatment  of  Rheumatism,  as  also  for  allow- 
ing me  to  test  the  respective  merits  of  topical  ap])lications 


X  PREFACE. 

in  several  well-marked  cases.  To  my  friend  and  colleague, 
Dr.  Bence  Jones,  my  best  thanks  are  due,  for  his  uniform 
kindness  in  affording  me  opportunities  of  treating  the 
disease  in  its  more  acute  and  terrible  form :  I  am  also 
indebted  to  Dr.  Blackall,  Senior  Physician  to  the 
Dreadnought  Hospital  Ship ;  to  Dr.  Fincham,  formerly 
Physician  to  the  Pimlico  Dispensary ;  and  to  several  other 
of  my  friends,  for  opportunities  of  treating  the  disease,  or 
of  witnessing  the  eflect  of  treatment. 

How  far  the  conclusions  at  which  I  have  arrived  will 
be  confirmed  by  further  experience,  time  alone  can  decide, 
but  the  labor  I  have  bestowed  upon  the  investigation 
will  not  have  been  thrown  away,  if  it  has  enabled  me  to 
make  some  little  addition  to  our  slender  stock  of  knowl- 
edge on  this  important  and  fearful  disease. 


PREFACE  TO  THE  SECOND  EDITION. 


The  favorable  reception  accorded  to  this  work  by  my 
professional  brethren  in  England,  as  also  in  America, 
where  it  has  been  reprinted,  has  encouraged  me  to 
undertake  its  complete  revision,  preparatory  to  the  issue 
of  a  second  edition.  Errors  have  been  corrected,  omis- 
sions supplied,  and  whatever  appeared  to  need  further 
elucidation  has  been  carefully  rewritten,  or  more  fully 
explained.  Throughout  the  work,  but  especially  in  the 
chapters  on  Rheumatic  Gout,  Chronic  Rheumatism,  and 
Sciatica,  much  additional  matter  has  been  inserted,  which, 
as  founded  on  a  large  number  of  personal  observations, 
backed  by  communications  received  from  medical  men  in 
various  parts  of  the  world,  will  be  found,  I  believe,  of 
practical  value. 

My  views  in  regard  to  the  treatment  of  the  acute 
disease  have  not  undergone  any  essential  modification 
since  the  year  1845,  when  I  first  had  recourse  to  full  and 
repeated  doses  of  alkalies  and  the  neutral  salts,  and  I  am 
glad  to  find  that  Dr.  Garrod  and  many  others,  who,  within 
the  last  four  years,  have  made  trial  of  these  remedies  in 
the  cure  of  Rheumatism,  have  confirmed,  to  the  letter, 
the  statements  made  in  the  first  edition  of  this  work. 


xii  PREFACE. 

It,  will  be  a  further  satisfaction  to  learn  that  the  sug- 
gestions thrown  out  in  tlie  present  edition,  relative  to  the 
successful  treatment  of  certam  chronic  forms  of  the  dis- 
ease, are  as  fully  borne  out  by  the  experience  of  others ; 
and  I  shall  deem  it  an  especial  favor  if  those  persons 
whose  opportunities  enable  them  to  throw  any  light  on 
the  subject,  will  kindly  favor  me  with  the  result  of  their 
observations. 


I 


CONTENTS. 


CHAPTER  I. 


INTRODUCTION. 

PAGE 

Rheumatism  deserving  of  attentive  study  ......     25 

Commonly  supposed  to  be  attributable  to  cold.     Not  so  in  reality     .         .     25 
General    and    local    effects   of  cold  as    ascertained   by  observation  and 

experiment  ...........     27 

Rheumatism  sometimes  ascribed  to  the  combined  influence  of  cold  and 

moisture.     Objections  to  this  theory  ......     29 

Probably  due  to  the  presence  of  a  morbid  matter  in  the  blood.     Argu- 
ments in  fixvor  of  this  doctrine  .         .         .         .         .         .         .         .32 

Source  of  this  morbid  matter.     Facts  in  support  of  its  being  a  product  of 

malassimilation,  or  vicious  metamorphic  action  .         .         .         .36 

Nature  of  the  poison.     Probably  lactic  acid      ......     40 

Specific  character  of  the  poison        ........     42 

Predisposing  and  exciting  causes  of  rheumatism       .         .         .         .         .44 

Recapitulation  and  views  of  author  as  to  the  action  of  the  rheumatic 

virus 47 


CHAPTER  n. 

ON  THB  RHEUMATIC  DIATHESIS,  AND  THE  CAUSES  WHICH  INFLUENCE  ITS 
DEVELOPMENT. 

Circumstances  which  favor  the  development  of  rheumatism  .  .  .49 
The  hereditary  character  of  rheumatism.     Statistical  observations  on  this 

subject       .         .         .         .         .         .         .         .         .         .         .         .51 

Age  at  which  the  disease  usually  appears 58 

Form  which  it  assumes  at  different  ages .59 

An  acute  attack  does  not  strengthen  the  disposition  to  the  disease  .  .  59 
The  class  of  persons  and  the  sex  most  liable  to  its  attacks  .  .  .  59 
The  effect  of  climate  and  season  on  its  production  .  .  .  .  .60 
Statistical  Reports  on  these  subjects 60 


xiv  CONTENTS. 


CHAPTER  III. 


ON  THE  SEAT  OF  RHEUMATISM,  AND  THE  CLASSIFICATION  OF  ITS  DIFFERENT 

VARIETIES. 

PAOB 

Differences  of  opinion  as  to  the  seat  of  rheumatism  .         .         .         .61 

All  parts  of  the  body  liable  to  suffer .     t3l 

The  white   fibrous   tissue  throughout   the  body  especially  liable  to  be 

attacked .     63 

Probable  explanation  of  this  fact      ........     64 

Those  joints  which  are  most  exposed  or  most  exercised,  and  those  which 
at  any  time  have  been  subjected  to  injury,  are  peculiarly  obnoxious 

to  an  attack 64 

Probable  explanation  of  this  circumstance        ......     65 

The  local  symptoms  assume  a  symmetrical  arrangement  .         .         .         .66 

Classification  of  rheumatism     .........     67 

Chief  characteristics  of  its  different  varieties .68 


CHAPTER  IV. 

ON  ACCTB  BHECMATISM,  OR  RHEUMATIC  FEVER. 

Acute  rheumatism,  or  rheumatic  fever.     Its  extreme  danger      .         .         .70 
Age  at  which  it  occurs.     Its  various  modes  of  attack        .         .         .         .70 

Its  symptoms,  general  and  local         .         .         .         .         .         .         .         .71 

The  fever  not  commensurate  with  the  extent  and  intensity  of  the  articular 

inflammation     ...........     75 

The  perspiration  often  spoken  of  as  "enfeebling  and  useless."     Not  so  in 

reality 77 

Symptoms  indicative  of  a  subsidence  of  the  disease  .         .         .         .79 

The  stiffness  which  remains  after  the  subsidence  of  the  acute  disease,  not 

to  be  mistaken  for  a  chronic  form  of  the  disorder       .         .         .         .80 
Duration  of  an  attack  of  acute  rheumatism  under  ordinary  methods  of 

treatment.     Opinions  of  different  authors  as  to  its  duration        .         .     80 

Statistical  Report  on  the  subject 84 

Can  the  paroxysm  be  immediately  arrested  or  cut  short  by  ordinary  tJ-eat- 
ment?     Grounds  for  author's  opinion  to  the  contrary,  and  explana- 
tion of  the  cases  which  are  often  cited  in  proof  of  such  an  occur- 
rence .         .         .         .         .         .         .         .         .         .         .         .81 

Result  of  author's  treatment  on  the  duration  of  the  disease      .         .         .81 
Various  complications  of  the  disease.     Their  severity  and  importance       .     83 


CONTENTS.  XV 


CHAPTER  V. 


ON    THE    TREATMENT    OF    ACITE    RHEUMATISM,    OR    RHEUMATIC    FEVER. 

PAGE 

Various   kinds  of  remedies  have  been  employed.     Treatment  hitherto 

uncertain  and  contradictory.     Cause  of  this  uncertainty         .         .       85 

Grounds  on  which  the  rational  treatment  of  acute  rheumatism  should  be 

based,  and  objects  to  be  effected 86 

Means  of  fulfilling  them  . 87 

Value  of  different  remedies  : 

Bleeding. — When   and  to  what  extent  to  be  employed.     Danger  which 

attends  its  injudicious  use  .  .....       88 

"          Buffing  and  cupping  of  the  blood  not  an  indication  for  its  repe- 
tition   92 

"         Opinions  of  various  physicians  as  to  its  efficacy       ...       92 

Purging. — When  and  to  what  extent  advisable.    Cautions  to  be  observed 

in  its  employment      ........       94 

Opium. — Ordinary  mode  of  administration  inefficient.  Dr.  Corrigan's 
method  of  treatment  by.  Result  of  author's  experience, 
with  suggestions  as  to  the  value  of  the  remedy  in  full  and 
repeated  doses  .  .         .  .         .         .         .         .97 

Vapor  and  Eot-Air  Baths. — Usually  unnecessary  in  the  acute  stage  of 

the  disease.     Under  what  circumstances  to  be  employed.     100 

Mercury. — If  given  so  as  to  affect  the  mouth  ahnost  always  prejudicial. 

When  and  how  to  be  administered     .....     101 

Tartar  Emetic. — Laennec's  opinion  in  regard  to.     To  be  employed  as  an 

adjunct  to  other  remedies  .         .         .         .         .         .102 

Cinchona. — Dr.  Haygarth's  method  of  administration.  Usually  dangerous 
in  the  active  stage  of  the  disease.  When  and  in  what  doses 
to  be  made  use  of       .         .         .         .         .         .         .         .103 

Colchicum. — Its  curative  power.  Its  poisonous  effects.  Class  of  cases  in 
which  it  is  most  strikingly  beneficial.  Cautions  to  be  ob- 
served in  its  administration         .         .         .         .         .         .104 

Guaiacum. — Dr.  Seymour's  report  as  to  its  modus  operandi.  Result  of 
author's  observation  as  to  its  curative  powers.  How  and 
when  to  be  employed 106 

Nitrate  of  Potash. — Report  of  various  physicians    as  to  the  action  of. 

Author's  opinion  as  to  its  efficacy       .....     107 

Lemon-Juice. — Effect  attributed  to  it  by  Dr.  Owen  Rees.  Usually  ineffi- 
cacious. Average  duration  of  the  disease  under  this  treat- 
ment   109 

Alkalies  and  their  Salts. — Their  exceeding  value  in  acute  rheumatism. 
Inoperative  in  ordinary  doses,  and  why.  Inadequate  to 
effect  a  speedy  cure  when  unassisted  by  other  remedies      .     Ill 

In  the  treatment  of  acule  rheumatism  each  remedy,  or  class  of  remedies, 

has  been  too  exclusively  relied  upon         .         .         .         .         .         .112 


XVI 


CONTENTS. 


Author's   method   of   treatment.      Its   ratiouale.      Success  which   has 

attended  it 115 

Value  of  topical  applications  as  adjuncts  to  the  general  treatment  .  118 
Experiments  to  prove  the  relative  value  of  different  topical  applications  119 
Experiments  tending  to  prove  that  articular  inflammation  may  be  in  some 

measure  prevented  by  judicious  fomentations  .  .  .  .119 
General  rules  for  the  diet  during  an  acute  attack  .  .  .  .  .120 
Cases  in  illustration  of  the  treatment  to  be  pursued  .  .  .  .120 
Remarks  on  the  effect  of  the  treatment  in  the  above  cases  .  .  .  132 
Observations  on  the  effect  of  the  treatment  in  several  other  cases         .     1 34 


CHAPTER    YI. 


ON     THE    CAU.SES    OF    RHEUMATIC    AFFECTION    OF    THE    HEART. 


Rheumatic  affection  of  the  heart  long  unknown  and  unsuspected    . 
Now  recognized  as  imparting  to  acute  rheumatism  its  chief  danger 
Not  generally  due  to  metastasis       ........ 

Information  respecting  the  cause  of  their  occurrence  to  be  gleaned  from 

an  inquiry  into  the  causes  which  determine  rheumatic  arthritis 
Treatment  most  effectual  in  preventing  the  access  of  cardiac  inflamma- 
tion ............ 

Inflammation  not  the  only  form  of  heart  disease  which  occurs  in  con- 
nection with  rheumatism.         ........ 

Grounds  of  this  opinion: 

Evidence  derived  from  the  symptoms  during  life 
"  "  post-mortem  examinations 

"  "  actual  experiment 

"  "  the  condition  of  the  blood 

"  "  the   difference  in    the    frequency   of 

"  "  CO  current  pulmonary    inflamma- 

"  "  tion  in  different  forms  of  rheumatic 

"  heart  affection 

Ohjcctions  to  this  opinion  answered         ....... 

Practical  hints  to  be  derived  from  this  view  of  the  subject 
Summary  of  author's  views  respecting  the  occurrence  of  rheumatic  in- 
flammation of  the  heart  ... 
Summary  of  author's  views  respecting  the  occurrence  of  fibrinous  deposi 
tion  on  the  endocardium 


137 
137 
138 

139 

144 

145 


j-      145-150 


150 
152 


153 


154 


CONTENTS.  XVU 


CHAPTER  VIT. 


RHEUMATIC      INFLAMMATION     OP     THE      HEART ITS     PATHOLOGICAL     EFFECTS — ITS 

SYMPTOMS,    PUOGHESS,    AND     TERMINATIONS. 

PAGE 

Anatomical  character  of  the  pericardium*:  nature  of,  and  products  result- 
ing from,  the  inflammation  to  which  it  is  subject.     Influence  which 
the  mechanism  of  the  pericardium  exerts  on  the  progress  and  term- 
ination of  pericarditis        .         .         .         .         .         .         .         .         .156 

Terminations  of  pericarditis.     Pathological  effects  observed   when  the 
disease  terminates  favorably,  and  also  when  unfavorably.  Condition 
of  the  parts  varies  greatly  according  to  the  period  which  has  elapsed 
since  the  commencement  of  inflammation         .....     157 

Pericardium,  when  once  inflamed,  rarely  restored  to  the  condition  of 

health 159 

Pathological  changes  produced  by  endocarditis.  Where  chiefly  observed     161 
The  appearances    presented  by  fibrinous  vegetations  vary  in   different 

cases,  and  at  different  stages  of  their  existence         .         .         .         .162 

Result  of  the  microscopic  examination  of  fibrinous  vegetations         .         .     163 
Consecutive  changes  Avhich  follow  the  deposition  of  fibrin  on  the  valves     164 
Comparative   danger  of  pericarditis   and  endocarditis,  and  the  conse- 
quences to  which  tliey  give  rise         .......     1G5 

Possibility  of  complete  recovery  after  an  attack  of  endocarditis         .         .     ]G7 
Great  improbability  of  complete  recovery  when  fibrinous  deposits  have 

taken  place  on  the  valves,  and  why IGf) 

Physical  signs  of  pericarditis. 

Friction-sound.    Referable   to  the   altered  mechanism  of  the 
parts.  Its  extreme  value  as  a  diagnostic  sign.  Two  different 
causes   of  its   cessation         .         .         .         .         .         .         .17(1 

Pra^cordial  dullness.    Not  pathognomonic  of  effusion,  but  valua- 
ble as  an  accessory  symptom  of  pericarditis,  and  as  indicating 
the  increase  or  decrease  of  effusion         .         .         .         .        .172 

Friction  thrill.     Its  usual  position.     Under  what  circumstances 

present 174 

Undulation.     Does  not  always  exist,  and  why         .         .         .     175 
Practical  inferences  to  be  deduced  from  these  signs,  more  especially  in 

reference  to  the  nature  of  the  prognosis 175 

Physical  signs  of  endocarditis. 

Bellows-murmur.     Referable  to  the  altered  mechanism  of  the 

valves,  and  how 177 

"             "               Mode  of  distinguishing  disease  of  the  differ- 
ent valves 17,S 

"  "  Difficulties  whicli  occasionally  present  them- 

selves in  forming  a  diagnosis.     How  to 
be  overcome     ......     182 


will 


CONTENTS. 


Goiicral  syniptonis  of  rheumatic  carditis.  Usually  more  marked  in  cases 
of  pericarditis  than  in  cases  of  endocarditis.  In  some  instances 
characteristic  :  in  some  altogether  absent.  To  be  valued  accordingly     184 

Head  symptoms,  when  occurring  in  the  course  of  acute  rheumatism, 
usually  symptomatic  of  cardiac  inflammation         .... 

Resume  of  the  principal  facts  relating  to  rheumatic  inflammation  of  the 
heart,  with  hints  as  to  the  prognosi.s  in  diff'erent  cases 

Abstract  of  16  fatal  cases  of  acute  rheumatism,  with  a  record  of  the  ap- 

jioarances  found  on  dis^^ection  .......     IRO 


186 


188 


CHAPTER  VIII. 


U.S     tin:    TRK.\T.\1KNT    OT     1IIIEU.\I.\TIC    1NKL.\M.\1  ATION    OF    THE    HE.\KT. 


Chief  i)0ints  for  consideration  in  reference  to  rheumatic  inflammation  of 

the  heart 204 

Calomel  given  so  as  to  affect  the  system  considered  by  some  persons  to 

be  a  safeguard  for  the  heart.     Not  so  in  reality         ....     20'' 

Those  remedies  only  can  assist   in  preserving  the  heart  from  mischief 
which  have  the  power  of  warding  ofl",  or  arresting,  an  attack  of  rheu- 
matism    ............     20G 

I'athological  conditions  to  be  attended  to  in  the  treatment  of  rheumatic 

cardiac  inflammation 207 

Venesection.     When,  and  how  far  serviceable         .....     20D 

Local  blood-letting  often  useful.     Leeching,  when  to  be  employed,  and 

when  cupping  .  .........     210 

.Mercury.     Its  action  in  rheumatic  carditis.     How   to  l)e  administered. 
Its   effects  sometimes  difllcult  to  obtain.     When   most   beneficial. 
When  prejudicial  to  the  patient's  safety  .         .         .211 

Opium.     Its  inestimable  value  in  these  cases.    Suggestion  as  to  whether 

it  may  not  exercise  some  directly  curative  influence         .         .         .     21.'> 
Rlisters.     Always  useful.   When  most  efiicient         .....     217 

Alkalies,  colchicum,  and  diuretics,  most  important  remedies    .         .         .217 
Rest  and  abstinence  of  the  utmost  consequence        .         .         .         .         .217 

.Symptoms  which  justify  the  commencement  of  active  treatment  ,  .         .     218 
Caution  to  be  observed  in  watching  for  any  mischief  .about  the  heart, 

even  during  the  patient's  convalescence    ......     221 

Treatment  to  be  .adopted,  when  much  irritability  of  the  heart  remains  222 

Cases  illustrating  the  author's  plan  of  treatment,  and  showing  the  in- 
fluence of  remedies,  and  the  share  which  each  remedj'  takes  in 
effecting  a  cure         ..........     223 


CONTENTS.  XIX 

CHAPTER  IX. 

ox   THE  STATISTICS  OV  HEAUT  DISEASE  IN'   CONNECTION  WITH  RHEUMATISM. 

PA<iK 

Statistical  records  of  rheunmtic  heart  affections,  most  important     .         .     23;) 
Dlfficnltics  wliich  present  themselves  in  instituting  a  comparison  between 

the  reports  of  various  observers        .......     235 

Cases  from  which  the  authors's  inferences  are  drawn       ....     237 

Table  exhiliiting  the  proportion  of  cases  in  which  some  form  of  heart 

affection  occurred I 

"  the  proportion  of  cases  in  wliiuh  recent  heart  affec- 

tion  occurred         ...... 

"  the  proportion  of  ca.ses  in  which  old-standing  heart 

disease  existed      ...... 

Inferences  as  to  the  proportion Avhich  ohl-standing  heart  disease  bear.'^  to 
acate  and  subacute  rheumatism  viewed  conjointly,  and  to  acute  and 
subacute  rheumatism  taken  separately     .         .  .         .         .240 

Proportion  of  diJses  of  acute  rheumatism  in  which  some  form  of  recent 
heart   affection   occurs,   as    shown    by   the    experience    of  various 
observers  ...........     240 

Facts  tending  to  corroborate  these  results        ......     240 

Proportion   of   cases   in  which  heart  affection    occurs   under   author's 

method  of  treatment         .........     240 

Observations  in  reference  to  the  frefiiiency  of  pericarditis  in  acute  ilieu- 

matism      .         .         .         .         .         .2  12 

•'  freciuency  of  recent  endocardial  affec- 

tion in  acute  rheumatism  .         .         .     24-'. 
"  relative  frequency  of  recent  exocardial 

and   endocardial    affection    in    acute 
rheumatism       .....     244 

Tables  exhibiting  the  result  of  these  observations  .....     24  I 

Author's  explanation  of  the  great  excess  in  the  frequency  of  endocardial 

affection  displayed  in  these  tables     .......     24ri 

Influence  of  age  in  determining  the  access  of  cardiac  affection        .         .     24  7 

"         of  sex 248 

Connection  which  e.tists  between  the  form  which  the  articular  symptoms 

assume  and  the  liability  to  heart  affection         .....     240 

Period  of  the  attack  at  which  heart  affection  most  commonly  arises        .     2.">(» 
Heart  affections  observed  less  frequently  in  primary  than  in  subsequent 

attacks  of  acute  rheumatism    ........     252 

Pericarditis  and  true  inflammation  of  the  endocardium  more  frequent  in 

primary  than  in  subsequent  attacks  of  acute  rheumatism  .  .  2:>:i 
T.vKLE  I. — Exhibitingthenumberof  cases  of  acute  and  subacute  rheuma- 
tism which  were  complicated  by  disease  of  the  heart;  the 
age  and  sex  of  the  patients  in  whom  it  occurred ;  tlic  form 
which  it  assumed ;  and  the  proportion  in  which  each  form 
occurred  anion"'  the  two  sexes     ......     2o.'5 


XX  CONTENTS. 

TAUB 

Table  II. — Exhibiting  tliu  same  facts  in  regard  to  acute  rheumatism, 

viewed  separately     ........     '2r)4 

"      III. — E.xhibiting  the  same  facts  in  regard  to  subacute  rhenma- 

tisni,  viewed  separately    .......     255 


CHAPTER  X. 

ox  AFFECTIONS  OF  THE  BlUl.S',  IXFLAMM ATIO.N  OF  TJIE  LUNGS  AND  PLECR/K,  AND 
DISORr.AXIZATION  OF  THE  JOINTS,  A.S  C0.MPLICATIUN3  AND  CONSEQUENCES  Or 
ACUTE  KHEU.MAT1SM. 

Delirium  occurring  in  the  course  of  acute  rheumatism,  formerly  referred 
to  inflammation  of  the  brain  :  sometimes,  though  rarely,  referable  to 
that  cause 257 

More  generally  connected  with  acute  inflannnation  of  some  internal 
organ,  and  occurs  sometimes  Mithout  any  concurrent  internal  in- 
flammation      ........         ^       .         .     258 

True  interpretation  of  the  head  symptoms  which  occur  in  acute  rheu- 
matism    ............     258 

Convulsions  and  spasmodic  actions  indicative  of  spinal  irritation,  arc  due 
to  precisely  the  same  circumstances  as  the  delirium  and  other  symp- 
toms referable  to  the  brain       ........     204 

Class  of  cases  in  which  cerebro-S])inal  symptoms  are  most  apt  to  arise. 

Case  in  illustration 2G5 

Cerebro-spinal  symptoms  always  indicative  of  extreme  danger,  but  not 

necessarily  of  a  fatal  issue       ........     265 

Cases  in  illustration  of  the  above-stated  facts : 

1st.  Cases  in  which  there  was  true  inflammation  of  the  brain  .     271 

2d.  Cases  in  which  there  was  acute  inflammation  of  some  internal 

organ,  but  no  inflammation  of  the  brain        ....     272 
3d.  Cases  in  which  there  was  neither  inflammation  of  the  brain,  nor 

of  any  other  internal  organ  .......     273 

Cases  illustrative  of  the  severity  which  spinal  symptoms  may  assume  in 

connection  with  acute  rheumatism  .......     277 

Cases  showing  that  recovery  may  take  place,  even  when  the  cerebro- 
spinal symptoms  are  most  alarming  ......     278 

Practical  suggestions  as  to  the  treatment  of  cases  in  which  cerebro- 
spinal symptoms  present  themselves         ......     27y 


Inflammation  of  the  lungs  or  pleuric,  a  most  formidable  complication  of 

acute  rheumatism.    ..........     282 

Frequency  of  its  occurrence    .........     28.3 

Result  of  Dr.  Latham's  experience.     Author's  e.xpcrience  at  St.  George's 

Hospital 283 

Circumstances  to  be  borne  in  mind,  in  the  treatment  of  rheumatic  in- 
flammation of  the  lungs 284 


CONTENTS.  XXI 


TAGE 


Cases  in  illustration  of  the  severity  of  the  symptoms,  and  of  the  treatment 

to  be  adopted           ..........  280 

Record  of  certain  fatal  cases,  with  the  j!)06-i-?rtor<em  appearances         .         .  288 

Disorganization  of  the  joints  is  anollier  formidable  complication  of  acute 

rheumatism      ........                   .         .  290 

Liability  to  its  occurrence  usually  varies  in  an  inverse  proportion  to  the 

number  of  joints  affected         ........  201 

Cases  in  illustration  of  the  treatment  to  be  adopted         ....  291 

Record  of  post-mortem  appearances  in  certain  cases         ....  292 

Summary  of  treatment  to  be  employed    .....                   .  294 

CHAPTER   XI. 

ON     UHEL-M.VTIC     GOUT. 

Rheumatic  gout  jjartakes  in  part  of  the  nature  of  rheumatism,  in  part  of 

that  of  gout,  but  is  not  identical  with  either.  Has  a  special  pathology  295 

In  its  acute  form  is  liable  to  be  mistaken  for  acute  rheumatism         .         .  290 

Closely  connected  with  malassimilation          ......  296 

Age  at  which,  and  sex  in  which,  it  most  commonly  occurs      .         .         .  297 

Symptoms  w-hich  mark  its  acute  attack           ......  297 

Complications  which  attend  it         .......         .  299 

Question,  whether  an  attack  which  commences  as  acute  rheumatism  may 

not  change  its  type,  and  terminate  as  rheumatic  gout         .         .         .  290 

Diagnosis  of  the  disease  in  a  chronic  form       ......  300 

Distortions  which  it  occasions         ........  301 

Nature  of  the  changes  induced  in  the  joints     ......  300 

Evidence  of  the  distinctive  character  of  the  disorder,  derived  from  the 

condition  of  the  joints  after  death      .......  304 

Mode  of  determining  the  nature  of  the  disease  when  deep-seated  joints 

are  affected       ...........  30G 

Treatment  of  the  acute  form  of  the  disease,  occurring  in  previously 

healthy  persons.     Remedies  which  prove  most  useful         .         .         .  307 
Means  to  be  employed  when  the  disease  remains  fixed  in  a  particular  point  310 
Benefit  to  be  derived  from  baths  of  various  descriptions         .         .         .311 
Treatment  to  be  adopted  when  the  patient  is  cachectic,  and  has  under- 
gone repeated  attacks  of  the  disease         ......  312 

Value  of  the  Fraxinus  excelsior,  the  arnica  raontana,  the  biniodide  of 

mercury  and  arsenic  in  certain  cases 318 

External  applications  which  prove  most  beneficial.    The  frequent  neces- 
sity for  their  use.     To  be  varied  according  to  the  nature  of  the  ' 
symptoms         ....          .......  324 

Plan  of  treatment  to  be  adopted  when  contraction  of  the  joints  has  taken 

place        .         .         .         .         .         .         .         .         .         .         .         .327 

General  rules  in  regard  to  diet,  exercise,  and  clothing     ....  329 


xxii  CONTENTS. 


PAHE 


Henelicial  inlluunce  of  change  of  scene  and  air,  and  curative  ett'ects  of 

various  thermal  springs.  Different  baths  useful  in  different  cases  .  o.'!2 
Cause  of  the. extreme  intractability  of  certain  cases  ....  .334 
Necessity  for  caution  in -watching  for  the  supervention  of  head-symptoms, 

and  for  taking  active  and  immediate  measures  for  their  subjugation  336 
Pleurisy  in  connection  with  rheumatic  gout.  When  most  dangerous  .  ;'37 
Deafness  as  a  complication  of  rheumatic  gout.     Its  cause  and  mode  of 

treatment  ...........     337 

Inllammation  of  the  eye.     Frequency   of  its  occurrence.     I'art  uf  the 

eye  affected.     Treatment  to  be  adopted     ......     338 

Cases  illustrative  of  the  treatment  of  rheumatic  gout       ....     340 

Table  exhibiting  the  temperature  and  constituents  of  various  thermal 

springs     ............     347 


CHAI'TKIl    XII. 

CUUO.MC    RHKfMATISM. 

Acute  and  chronic  rheumatism  identical  in  their  .source  and  nature.  The 
acute  may  lapse  into  the  chronic  form,  and  the  chronc  may  light  up 
into  an  active  state  .  .         .         .         .         .  .351 

Parts  principally  affected  in  chronic  rheumatism     .....  352 

Muscular  rheumatism,  ciiaracter  of  the  pain 3.52 

Lumbago.     Symptoms.     If  neglected,  apt  to  be  very  obstinate        .         .  353 

Stiff  or  wry  neck.     Character  of  the  pain 354 

Intercostal  rheumatism.     Pain  increased  by  inspiration.     How  to  be  dis- 
tinguished from  pleurisy 354 

Muscular  rheumatism  often  leads  to  wasting  of  the  limb         .         .         .  355 
Symptoms  -which  characterize  affection  of  llie  ligaments,  and  the  struc- 
tures surrounding  the  joints 355 

Symptoms  which  accompany  affection  of  the  bursa'  and  synovial  mem- 

'jrane 35G 

Gonorrhocal  rheumatism.     Its  nature  and  symptoms.     Eyes  often  impli- 
cated.    Apt  to  be  extremely  obstinate 356 

Periosteal  rheumatism.      Its  symptoms 358 

Pain  of  nodes  on  the  cranium  liable  to  be  mistaken  for  ordinary  hcad- 

•■iche 3J8 

Class  of  patients  among  whom  periosteal  rheumatism  is  most  common  359 

Pains  of  chronic  rheumatism  most  severe  at  night        .         .         .         .  35!;» 

"                "            sometimes  aggravated  by  heat         .         .  300 

Points  to  be  remembered  in  the  treatment  of  chronic  rheumatism  .         .  360 
Valuable  properties  of  the  ammoniated  tincture  of  guaiacum.     How  to 

be   used                     ••........  361 

The  Mistura  Guaiaci  and  jiowdcred  guaiacum.     When  serviceable          .  :!62 

Tcrcbintbinate  medicines  often  bcuclicial 36.'! 


CONTEXTS. 


xxin 


Sassafras  in  man)-  cases  a  useful  remedy         ..... 

Diluents  extremely  serviceable  in  aid  of  other  remedies 

Sulphur  often  beneficial  .         .         .         .         .         .         .      ■  . 

Colchicum,  when  useful  .         .         .         .         .         .         .         . 

loidide  of  potassium.     Most  efficient  in  periosteal  rheumatism 
Mezereon,  when  and  how  to  be  employed         ..... 

Cod-liver  Oil.     When  and  how  far  beneficial  ..... 

Hydrochlorate  of  Ammonia  of  great  value  in  muscular  rheumatism 
Arsenic  extremely  useful  when  tlie  skin  is  harsh,  and  tliere  is  a  want  of 

tone  and  nervous  energy  ........ 

Mercury,  when  to  be  employed,  and  in  what  form    .... 

Value  of  opiates      .         .         ... 

Other  sedatives — belladonna,  stramonium,  conium,  hyoscyamus.  and  the 

Cannabis  Indica — often  serviceable  ...... 

Aconite  a  very  valuable  remedy.     Class  of  cases  in  which  it  is  mosi 

efficacious 

Purgatives.     When  most  useful        ....... 

Local  applications  of  great  efficacy  in  lumbago  and  stiff  neck 
Sir  Anthony  Carlisle's  hot  iron.     Mode  of  applying  it     . 
Effects  of  a  frigorific  mixture  as  applied  by  Dr.  J.  Arnctt 
Oil  of  turpentine  very  useful  in  lumbago  ..... 

Benefit  to  be  derived  from  baths      ....... 

Blisters,  when  to  be  made  use  of     ......         . 

Liniments  and  fomentations  useful,  not  only  in  muscular  rheumatism 

but  also  when  the  joints  are  affected       ..... 
Aconitine   and  veratria   ointments.     Their  singular   eflicacy  in   certain 

cases         ........... 

An  alcoholic  solution  of  Aconitine  to  be  employed,  when  the  ointment  is 

inapplicable      .......... 

Precautions  to  be  taken  against  cold,  when  the  patient  leaves  the  house 
Electricity,  galvanism,  and  acupuncturation.     Their  respective  merits  as 

curative  agents         .......... 

Good   results   occasion.ally  accrue  from   a  brief  residence  in   a  warm 

climate        ........... 


PAGE 

363 
364 
365 

365 
365 
366 
366 
367 


367 

36S 
371) 


370 

371 
373 
374 
375 
376 
378 
378 
379 

380 

380 

381 
3«1 


382 


CHAPTER  XIIL 


ON  S('I.\TI(:A,  and  OTHKR  forms  of  NEUIIALGIC  RHEUMATISM. 

Rheumatism  which  attacks  the  nerves,  easily  distinguished  from  other 

forms  of  rheumatism         .........  384 

Position  and  character  of  the  pain  in  sciatica  .....  384 

Age  at  which,  and  sex  in  which,  it  most  frequently  occurs      .         .         .  385 

Apt  to  prove  intractable,  and  the  reason  why  .....  386 


xxiv  CONTENTS. 

PAOB 

Points  to  be  ascertained  before  deciding  upon  a  plan  of  treatment  .         .     387 
Diseases  which  have  been  mistalceu  for  sciatica,  and  bow  they  may  be 

distinguished 387 

Nature  of  the  treatment  dependent  on  a  due  recognition  of  the  primary 
cause  of  the  disease,  as  also  of  the  stage  at  which  the  complaint 
has  arrived       ...........     388 

Diagnosis  of  effusion  into  the  sheath  of  the  nerve 390 

Remedies  which  prove  most  useful  in  checking  effusion,  and  in  pro- 
moting its  absorption       .........     393 

Acupuncturation,  when  and  how  far  serviceable     .....     394 

Effusion  into  the  sheath  of  the  nerve  by  no  means  a  common  occur- 
rence  395 

Opium,  belladonna,  stramonium,  hyoscyamus,  conium,  and  the  Cannabis 
InJica — their  value  as  sedatives.     Their  mode  of  action.     Points  to 
be  borne  in  mind  before  deciding  on  their  administration         .         .     395 
Efficacy  of  this  class  of  remedies  when  applied  externally       .         .         .     307 
Extraordinary  effect  when  injected  into  the  cellular  tissue       .         .         .     398 
Digitalis,  aconite,  and  veratria:  their  antineuralgic  properties,  the  mode 
in  which  they  should  be  employed,  and  the  class  of  cases  in  which 
their  curative  influence  is  displayed  ......     401 

Blisters,  moxas,  and  the  actual  cautery  :  their  respective  merits      .         .     404 
Galvanism  and  electricity,  cases  in  which  they  prove  most  serviceable    .     406 

Congelation,  its  effects    . 406 

Firm  and  continued  pressure,  good  results  attributed  to  it       .         .         .     408 
Extraordinary  efficacy  of  sulphur  applied  externally        ....     409 

Stimulating  liniments  and  other  external  applications  have  been  made 

use  of.     Which  most  serviceable     .......     409 

Influence  of  baths,  and  the  natural  mineral  waters,  as  curative  agents    .     411 
Local  baths  of  various  descriptions  of  the  greatest  service      .         .         .     412 
Quinia,  iron,  zinc,  arsenic,  and  other  tonics:  their  mode  of  action,  and 

the  circumstances  under  which  they  prove  beneficial        .         .         .     413 
Frequent  connection  of  sciatica,  and  other  forms  of  neuralgic  rheuma- 
tism, with  the  presence  of  oxaluria.     Treatment  required  in  such 
cases.     Its  modus  operandi      ........     413 

Points  to  bo  remembered  in  the  diagnosis  of  rheumatic  affection  of  other 

nerves      .         .         .         .         .         .         .         .         .         .         .         .415 

In  these  instances,  as  in  the  case  of  sciatica,  a  correct  diagnosis  is  essen- 
tial to  the  adoption  of  eflicient  remedies  .         .         .         .         .415 

External  applications  which  have  been  found  serviceable      ^ .         .         .410 
Cases  illustrative  of  the  treatment  of  sciatica  and  facial  neuralgia  .     41G 


RHEUMATISM,   RHEUMATIC  GOUT 


SCIATICA. 


CHAPTER  I. 

INTRODUCTION. 

"  Quamvis  enim  cedere  auctoritate  debeani,  rectius  tamen  arbitror,  in 
tanta  re,  ratione  quam  auctoritate  superari." — Pliny,  Lib.  i,  Ep.  20. 

Few  diseases  are  more  deserving  of  attention  than  that  com- 
oaon,  painful,  and  obstinate  malady  which  has  been  recognized 
under  the  title  of  Rheumatism.  Whether  vicAved  in  relation  to 
the  number  of  its  victims,  the  amount  of  present  suffering  it 
inflicts,  or  the  terrible  disease  of  the  Heart  which  it  entails,  it 
ranks  among  the  most  formidable  of  human  ailments.  Its  im- 
portance, however,  in  the  estimation  of  the  physiologist  is  de- 
rived, not  only  from  its  prevalence  and  severity,  but  from  the 
mystery  in  which  it  has  ever  been  involved.  Obscure  in  its 
origin,  and  in  its  subsequent  course  uncertain  and  variable,  its 
source  has  hitherto  remained  undiscovered,  its  phenomena  un- 
explained, its  treatment  unsatisfactory ;  and,  by  common  con- 
sent, it  is  ascribed  to  a  cause  which  affords  not  the  slightest 
clew  to  its  nature,  nor  the  least  explanation  of  its  varied  phe- 
nomena. 

Many  persons  consider  exposure  to  cold  sufficient  to  induce 
an  immediate  attack  ;  and  though  rheumatism  not  unfrequently 
occurs  without  the  slightest  exposure,  though  even  when  ex- 


26  INTRODUCTION. 

posure  lias  taken  place,  fresh  joints  are  attacked  long  after  all 
exposure  has  ceased ;  nay,  more,  though  the  ascertained  local 
and  general  effects  of  cold  differ  altogether  from  the  symptoms 
of  rheumatism,  yet  some,  even  among  the  profession,  have 
been  found  to  adopt  this  prevalent  notion,  without  an  attempt 
to  show  that  cold  either  does  or  can  produce  the  effects  assigned 
to  it. 

Others  have  endeavored  to  point  out  the  precise  nature  of 
the  influence  exerted,  and  have  suggested  that  cold,  by  sus- 
pending cutaneous  secretion,  and  so  giving  rise  to  the  retention 
of  effete  matters  in  the  blood,  is  explanatory  of  the  varied  phe- 
nomena of  the  disease.  But  rheumatism  may,  and  does  some- 
times occur  under  circumstances  which  entirely  preclude  the 
agency  of  cold  ; — it  is  not  by  any  means  of  common  occurrence, 
even  when  the  skin's  function  is  suspended  by  disease ;  and 
when  once  it  has  arisen,  it  sometimes  continues  with  great 
severity  for  months  after  the  action  of  the  skin  has  been  re- 
established, and  profuse  and  constant  perspiration  has  been 
set  up. 

By  others,  a  temporary  exposure  to  cold  has  been  justly 
deemed  insufficient  to  account  for  symptoms  so  severe  and 
erratic  in  their  nature,  so  variable  in  their  mode  of  onset,  and, 
in  many  cases,  so  extremely  obstinate  in  their  continuance. 
Accordingly,  of  late  years,  a  theory  has  been  broached  more 
consistent  with  the  train  of  physical  events,  and  rheumatism 
has  been  referred  to  the  irritation  of  a  morbid  matter  in  the 
blood,  which  though  possibly  derived,  in  part,  from  the  stop- 
page and  consequent  retention  of  the  perspiration,  through  the 
influence  of  cold,  is,  to  a  far  greater  extent,  generated  in  the 
system,  as  a  product  of  impaired  or  perverted  assimilation — of 
vicious  matamorphic  action. 

This  doctrine  is  as  yet  imperfectly  understood,  and  even  by 
its  warmest  advocates  has  been  hardly  carried  to  its  legitimate 
conclusion.  It  may  be  well,  therefore,  to  explain  the  grounds 
on  which  its  acceptance  rests,  to  point  out  the  universality  of 
its  application,  and  to  show  how  important  is  its  practical 
bearing.  a 


INTRODUCTION.  27 

First,  however,  it  will  be  necessary  to  advert  to  the  local 
and  general  elFects  of  exposure  to  cold,  as  actually  proved  by 
experience. 

When  any  part  of  the  body  is  subjected  to  a  low  temperature, 
or  to  the  combined  influence  of  cold  and  moisture,  the  first 
symptom  of  such  exposure  is  a  sensation  of  cold  in  the  part 
exposed,  accompanied  by  a  pallor  or  blueness  of  the  skin.  If 
the  exposure  be  of  short  duration,  and  the  degree  of  cold  mod- 
erate, the  circulation  is  soon  re-established  after  removal  from 
the  cold,  and  no  ill  results  ensue. 

When  the  degree  of  cold  is  greater,  or  the  exposure  of  longer 
duration,  a  shrunken  state  of  the  skin  supervenes,  the  circu- 
lation in  the  part  is  partially  and  sometimes  almost  entirely 
arrested,  and  when  warmth  is  again  applied,  gangrene  may 
result,  if  care  be  not  taken  to  prevent  reaction  taking  place 
too  rapidly.  If  proper  caution  is  observed,  nothing  unusual 
is  remarked  in  the  part  beyond  a  temporary  glow  or  increased 
heat,  which  gradually  subsides  altogether. 

If  the  intensity  of  the  cold  be  still  greater,  or  exposure  even 
to  a  moderate  degree  of  cold  be  of  longer  duration,  the  parts 
exposed  Avill  probably  be  frost-bitten  and  become  gangrenous 
and  die.  In  every  instance  the  local  effects,  though  varying 
somewhat  in  different  persons,  are  proportioned,  cseteris  paribus, 
to  the  intensity  of  the  cold  and  the  duration  of  the  exposure, 
and  are  manifested  only  in  the  parts  exposed. 

Y[ie  general  effects  of  exposure  to  cold  are  equally  well  known, 
and  are  also  strongly  marked.  Up  to  a  certain  point,  which 
varies  in  different  individuals  according  to  their  condition  and 
the  activity  of  the  circulation,  cold  evidently  acts  as  a  decided 
stimulus.  It  produces  muscular  contraction,  and  imparts  vigor 
to  the  system.  But  intense  cold,  or  long-continued  exposure 
even  to  a  moderaiie  degree  of  cold,  has  a  directly  opposite 
effect.  It  gives  rise  to  chilliness,  or  even  shivering,  with  mus- 
cular and  nervous  exhaustion,  a  diminution  in  the  force  of  the 
heart's  action,  and  general  depression  of  all  the  natural  func- 
tions. This  depressing  influence  may  proceed  to  such  an  extent 
as  to  produce  a  species  of  stupor,  an^almost  irresistible  desire 


28  INTRODUCTION. 

to  sleep,  with  excessive  feebleness  of  the  heart's  action,  and 
death  as  its  natural  result. 

It  will  be  observed  that  the  phenomena  primarily  produced 
by  cold  are  totally  unlike  the  symptoms  of  rheumatism.^  No 
wandering  pains ;  no  redness  or  swelling  of  the  joints ;  no  symp- 
toms, indeed,  of  any  moment  present  themselves  unless  the  cold 
be  intense,  and  even  then  they  bear  no  resemblance  to  the  ' 
symptoms  of  rheumatism.  Nay,  more  than  this:  the  experi- 
ence of  travelers  has  proved  beyond  all  question,  that  in 
healthy  persons,  the  most  extreme  and  rapid  variations  of  tem- 
perature are  insufficient  to  excite  the  disease.^ 

Some  persons,  however,  maintain  that  cold,  though  of  itself 
inert,  becomes  a  poAverful  agent  in  the  production  of  rheumatism 
when  acting  in  conjunction  with  damp  and  moisture.     Doubt- 

1  I  employ  the  word  primarily  with  the  view,  firstly,  of  pointing  out  that 
rheumatism  does  not  occur  as  an  immediate  effect  of  mere  abstraction  of  heat ; 
and,  secondly,  of  guarding  against  the  supposition  that  cold  is  never  concerned 
in  its  production.  It  will  be  seen,  in  the  latter  part  of  this  chapter,  that  cold 
does  sometimes  prove  the  efficient  cause  of  the  disease,  by  exercising  a  depress- 
ing influence,  interfering  with  the  business  of  nutrition,  and  so,  through  per- 
verted assimilation,  giving  rise  to  the  formation  of  the  materies  morbi.  But 
I  wish  it  to  be  distinctly  understood,  that  mere  abstraction  of  heat  will  not 
produce  rheumatism,  except  in  the  indirect  manner  just  alluded  to,  and  that 
the  disease,  therefore,  cannot  be  attributed  strictly  to  cold.  The  only  true  or 
essential  cause  of  the  disease  is  a  poison  in  the  blood,  the  formation  of  which 
may  be  occasioned  by  many  accidental  causes  of  perverted  nutrition,  of  which 
exposure  to  cold  is  one. 

-'  Captain  Parry,  in  his  account  of  "  A  Voyage  for  the  Discovery  of  a  North- 
west Passage,"  observes,  (p.  134,)  "  We  were  constantly  in  the  habit  for  some 
mouths  of  undergoing  a  change  of  from  80°  to  100°,  and  in  several  instances 
of  120°  of  temi)erature  in  less  than  a  minute  ;  and  what  is  most  extraordinaryi 
not  a  single  infiammatory  complaint,  beyond  a  slight  cold,  which  was  cured  by 
common  care  in  a  day  or  two,  occurred  during  this  particular  period."  Through- 
out the  expedition,  the  occurrence  of  rheumatism,  or,  indeed,  even  of  rheumatic 
pains,  was  exceedingly  rare. 

Again,  Colonel  Sir  J.  Mitchell,  in  his  "  Journal  of  an  Expedition  into  the 
Interior  of  Tropical  Australia,"  reports  that  "  they  were  subjected  almost  daily 
to  variations  of  temperature  of  nearly  50°,"  and  yet  he  makes  no  mention  of 
the  occurrence  of  rheumatism. 

And  again,  it  appears  from  the  statistical  reports  of  cases  which  have  occurred 
among  our  troops  stationed  in  different  parts  of  the  world,  that  out  of  every 
1,000  patients  admitted  into  the  military  hospitals,  there  are  fifty-seven  cases 
of  rheumatism  at  the  Cape  of  Good  Hope,  the  land  of  heaths  and  geraniums, 
and  thirty  only  in  the  cold  and  variable  climate  of  Nova  Scotia  and  New 
Brunswick. 


INTRODUCTION.  29 

less,  under  such  circumstances,  it  proves  an  active  predisposing 
cause  of  this,  in  common  with  many  other  disorders;  and  it 
may  also  become  an  exciting  cause  when  a  predisposition  already 
exists.  But  the  significant  fact,  that  numberless  persons  are 
constantly  exposed  to  the  combined  influence  of  cold  and  moist- 
ure, and  that  nevertheless  no  instance  is  on  record  in  which 
rheumatism  has  occurred  simultaneously  in  any  large  number 
of  persons,  is  sufficient  to  show  that  the  influence  alluded  to 
cannot  be  the  proximate  or  essential  cause  of  the  disease. 
Amidst  all  the  horrors  of  the  Russian  campaign,  with  sleet 
falling,  and  men  dying  on  all  sides  from  the  effects  of  cold  and 
wet,  it  was  hardly  more  prevalent  than  at  any  other  time  ;*  and 
the  same  observation  has  been  made,  when  soldiers,  heated  by 
their  march  and  drenched  to  the  skin,  have  had  to  repose  on 
the  cold  wet  ground.^ 

Indeed,  it  needs  little  observation  to  prove  tliat  cold  and 
atmospheric  vicissitudes  are  not  essential  to  the  production  of 
rheumatism.  Persons  in  private  life  are  frequently  seized  with 
active  symptoms  of  the  disease  without  having  been  subjected 
to  the  slightest  exposure ;  and  in  hospital  practice,  patients  who 
have  been  admitted  for  some  other  complaint,  and  have  been 
confined  to  bed  for  weeks  in  a  ward  heated  up  to  65°  Fahren- 
heit, are  sometimes  attacked  by  it  in  a  most  violent  manner. 
In  such  instances  the  symptoms  are  just  as  severe,  and  continue 
just  as  obstinately  as  in  cases  where  there  has  been  the  greatest 
exposure.^ 

1  During  the  three  or  four  exceedingly  cold  days  which  immediately  pre- 
ceded the  battle  of  Eylau,  the  mercury  had  fallen  to  10,  11,  12,  13,  14,  and  15 
degrees  below  zero,  of  Reaumur's  thermometer,  (or,  in  other  words,  to  below 
zero  of  Fahrenheit;)  and  during  these  days,  and  during  a  great  portion  of  the 
nights  of  the  5th,  6th,  7th,  8th,  and  'Jth  of  February,  "  the  soldiers  had  been 
exposed  to  the  snow  and  frost,"  yet  "  no  ssldier  presented  himself  at  the  am- 
bulance," and  "it  was  not  until  the  night  of  the  10th,  when  the  temperature 
had  risen  about  18  or  20  degrees,  that  they  felt  the  first  effects  of  cold."  They 
then  began  to  suffer,  not  from  rheumatism,  but  from  "  gangrene  of  the  extremi- 
ties, one  of  the  common  and  true  effects  of  cold." — (Baron  Larrey's  "  Memoires 
de  Chirurgie  Jlilitaire,"  vol.  iii.) 

'^  Pringle's  "Observations  on  Diseases  of  the  Army." 

3  Numberless  cases  of  this  sort  might  be  cited,  but  one  which  T  take  at  ran- 
dom from  my  note-book  will  suffice  for  an  illustration  of  the  subject.   William 


30  INTRODUCTION. 

But  more  than  this:  it  frequently  happens  that  some  ten 
(lays  after  the  commencement  of  an  attack,  the  knee,  or  some 
part  which  had  previously  escaped,  hecomes  hot  and  red,  and 
swollen.  Whatever  the  cause  of  the  first  articular  inflammation, 
the  fresh  inflammation  cannot  reasonably  be  attributed  to  the 
efi'ect  of  cold,  inasmuch  as  from  the  patient  being  confined  to 
bed,  the  joints  are  necessarily  protected  from  its  influence.  In 
order,  therefore,  to  account  for  this  singular  phenomenon,  a 
vague  and  untenable  hypothesis  has  been  resorted  to;  and  it 
has  been  suggested,  that  the  fresh  inflammation  set  up  is  due 
to  a  transference  of  inflammatory  action  from  another  part  of 
the  body.  In  some  instances  such  may  be  the  case,  but  obser- 
vation has  proved  that  it  is  usually  a  mere  extension  of  the 
disease,  occurring  where  no  subsidence  of  inflammation  has 
taken  place. 

Sometimes  when  the  complaint  has  nearly  run  its  course,  and 
the  pain  and  inflammation  have  in  great  measure  subsided,  the 
symptoms  recommence  in  all  their  severity  without  fresh  expo- 
sure, and  without  any  obvious  exciting  cause.  Even  had  the 
first  attack  arisen  from  cold,  the  recurrence  of  the  disease  with- 
out fresh  exposure  proves  it  totally  independent  of  any  such 
agency. 

The  same  fact  is  fully  and  unequivocally  attested  by  the 
history  and  entire  progress  of  the  complaint.  The  articular 
symptoms  of  rheumatism  are  extremely  migratory ;  they  do  not 
cease  on  the  re-establishment  of  perspiration,  and  they  are 
sometimes  preceded,  and  after  a  time  very  frequently  accom- 

Edmonds,  aet  34,  who  was  admitted  into  St.  George's  Hospital  on  the  30th  of 
April,  1840,  under  the  care  of  Mr  Keate,  was  contined  to  his  bed  by  severe 
ulceration  of  his  leg.  He  was  much  out  of  health,  but  presented  no  symptoms 
of  rheumatism  until  the  2oth  of  May,  when,  after  lying  in  bed  for  a  period  of 
nearly  four  weeks,  he  was  seized  with  wandering  rheumatic  pains.  These 
gradually  increased  in  severity,  and  on  the  1st  of  June  his  right  hip  became 
exquisitely  painful,  and  both  his  hands  and  wri.^ts  red,  swollen,  and  inflamed) 
In  short,  an  attack  of  acute  rheumatism  commenced,  and,  in  spite  of  treatment, 
ran  its  usual  course.  Sueh  instances  have  not  escaped  the  notice  of  the  ob- 
servant Mons.  Chomel ;  and,  accordingly,  after  quoting  several  in  point,  he  has 
expressed  it  as  his  opinion,  (''Lemons  de  Clinique  Medicale,"  torn,  ii,  p.  153,) 
that  "  the  impression  of  cold  is  not  a  necessary  precursor  of  acute  rheumatism." 


INTRODUCTION.  31 

panied  by  inflammation  of  tlie  membranous  envelopes  of  the 
heart. 

If  they  were  due  to  cokl,  locally  applied,  they  should  surely 
be  stationary,  as  are  all  local  symptoms  known  to  depend  on 
local  causes:  if  due  to  the  repression  of  the  perspiration  by 
cold  they  should  certainly  cease,  or  be  relieved  in  some  measure 
by  the  re-establishment  of  the  skin's  action ;  the  more  so,  as  in 
rheumatism  the  perspiration  is  excessive,  and  in  its  duration 
most  remarkable :  and  if  referable  to  cold  the  heart  should 
surely  escape  unscathed,  protected  as  it  is  on  all  sides  from  the 
influence  of  cold.  On  this  point  experience  speaks  decisively, 
and  shows  that  for  some  time  the  heart  is  not  afi'ected  even 
under  the  influence  of  intense  cold;  and  that  when  after  pro- 
longed exposure  it  is  aff"ected  even  unto  death,  not  the  slightest 
inflammatory  action  is  produced,  but  its  impulse  becomes  feeble, 
after  a  time  irregular,  and  ultimately  ceases  altogether.  On 
what,  then,  do  the  symptoms  of  rheumatism  depend? 

If  certain  substances  are  introduced  into  the  circulation, 
fever  is  set  up,  rigors  often  occur,  and  inflammatory  symptoms 
very  shortly  supervene  in  various  parts  of  the  body;  symptoms 
which  vary  in  intensity  and  locality,  according  to  the  amount 
and  character  of  the  poison.  And  if  the  blood  be  altered  in 
character  it  is  practically  the  same,  whether  it  contain  matters 
foreign  to  the  system  and  altogether  morbid  in  kind,  or  whether 
it  contain  an  excess  only  of  some  material,  a  certain  amount  of 
•which  is  compatible  with  health.  In  either  case  it  is  unhealthy 
and  poisonous  in  its  nature ;  in  either  case  it  contains  a  "  materies 
morbi,"  which  may  not  only  produce  fever,  or  the  symptoms  of 
general  derangement,  but,  if  irritating  in  its  nature,  may  give 
rise  to  local  inflammatory  symptoms.  Assuming,  then,  that 
an  abnormal  condition  of  the  blood  may  account  for  the  pain, 
inflammation,  and  the  curious  train  of  symptoms  which  consti- 
tute an  attack  of  acute  rheumatism,  I  shall  endeavor  to  show 
that  such  a  condition  does  actually  exist  in  this  disease,  and 
that  it  is  mostly,  if  not  wholly,  referable  to  constitutional  causes. 

Many  of  the  most  remarkable  features  of  rheumatism  are 
quite  characteristic  of  a  disease  dependent  on  a  vitiated  con- 


32  INTRODUCTION. 

dition  of  the  circulating  fluid.  Its  attacks  are  ushered  in  by 
premonitory  fever ;  its  local  symptoms  are  erratic,  and  yet 
remarkably  symmetrical  in  their  arrangement :  the  heart,  the 
lungs,  and  other  internal  organs  are  prone  to  be  affected ;  and 
when  metastasis  occurs,  the  constitutional  symptoms  are  such 
as  are  met  with  under  similar  circumstances  in  diseases  known 
to  be  connected  with  a  vitiated  blood. 

In  some  cases,  the  fever  is  at  first  so  slight  as  hardly  to 
attract  attention  ;  and  then,  as  in  instances  occasionally  met 
with  among  the  eruptive  fevers,  the  appearance  of  the  local 
symptoms  affords  the  first  noticed  indication  of  existing  dis- 
ease. But  more  commonly  the  patient  has  been  "  out  of 
sorts,"  for  some  time  prior  to  the  full  development  of  the 
attack ;  he  has  probably  felt  languid,  chilly,  and  uncomfort- 
able ;  the  appetite  has  been  capricious ;  he  has  had  a  sour  or 
bitter  taste  in  his  mouth,  and  has  experienced  dull,  aching 
pains  in  the  limbs ; — symptoms  which  indicate  constitutional 
derangement,  and  together  mark  the  onset  of  fever.  And  it 
will  be  observed  that,  in  many  important  respects,  this  rheu- 
matic fever  differs  from  that  which  results  from  local  mischief. 
The  fever  which  accompanies  local  affections  is  invariably 
developed  after  the  commencement  of  local  mischief,  is  com- 
mensurate with  its  intensity,  and  decreases  or  increases  in 
exact  proportion  to  the  extent  and  intensity  of  the  local  mis- 
chief; whereas  in  i-heumatism,  as  in  other  diseases  known  to 
be  dependent  on  a  poisoned  blood,  it  generally  precedes,  for  a 
considerable  time,  the  full  development  of  the  local  symptoms, 
not  unfrequently  decreases  directly  local  inflammation  is  set 
up,'  and  is  invariably  aggravated  by  its  sudden  or  premature 
subsidence. 

So  also  in  regard  to  the  erratic  natm-e  of  the  articular 
inflammation.  When  inflammatory  action  is  excited  by  a 
truly  local  cause,  as,  for  instance,  by  a  blow,  nobody  ever 
imagines  that  it  can  possibly  subside  in  the  spot  first  affected, 

'  "  Febri3  nutem  scnsem  evanescit,  manente  dolore,  quin  et  nonnunquam 
inmanius  sa^viente,  materia  scilicet  febriii  in  artus  translata."  (Sydenhami 
Opera,  sect,  vi,  cap.  v.) 


INTRODUCTION.  33 

and  reappear  in  some  distant  part  of  the  body.  On  the  con- 
trary, it  is  an  admitted  fact  that,  when  any  mischief  is  really 
local,  the  inflammation  is  also  lo(!al  and  stationary.  On  the 
other  hand,  whenever  the  blood  is  poisoned,  as  when  pus,  for 
instance,  has  been  taken  into  the  circulation,  we  are  never 
surprised  at  the  occurrence  of  symptoms  in  any  part,  however 
distant  from  the  original  seat  of  mischief,  inasmuch  as  the 
poison  circulates  with  the  blood  to  every  tissue  of  the  body, 
and  may  irritate  and  ultimately  excite  inflammation  in  several 
parts  successively.  Thus  the  joints,  the  heart,  the  lungs,  and 
the  nervous  centers,  may  be  affected  simultaneously  or  in  suc- 
cession, while  the  functions  of  the  skin,  the  liver,  and  the 
kidneys  may  also  be  more  or  less  interfered  with.  Such,  also, 
is  the  case  in  regard  to  rheumatism. 

On  the  same  ground,  the  symmetry  of  the  local  symptoms 
of  the  disease  affords  additional  evidence  of  the  poisoned  con- 
dition of  the  circulating  fluid.  For  if  the  blood  itself  be  at 
fault,  it  is  but  consistent  with  reason  to  suppose  that,  perme- 
ating as  it  does  every  tissue  of  the  body,  it  should  ultimately 
give  rise  to  similar  changes  in  parts  corresponding  in  function 
and  organization,  whereas,  under  any  other  supposition,  the 
proneness  of  the  disease  to  affect  similar  parts  on  either  side 
of  the  body  is  utterly  inexplicable.  The  peculiarity  in  ques- 
tion has  been  shown  by  Dr.  W.  Budd'  to  obtain  in  all  disorders 
connected  with  a  vitiated  condition  of  the  circulation,  and  why 
take  exception  to  rheumatism ;  why  exclude  a  disease  pre- 
senting such  curious  illustrations  of  the  fact  ? 

Again,  that  inflammation  of  the  heart  is  liable  to  arise,  and 
forms  one  of  the  most  frequent  as  it  is  one  of  the  most  formi- 
dable complications  of  rheumatism,  is  a  fact  most  painfully 
verified  by  experience,  and  it  is  equally  certain  that  it  some- 
times occurs  prior  to  the  setting  up  of  any  articular  or  other 
external  symptom  of  the  disease.^  In  casea  where  it  is  pre- 
ceded by  pain,  redness,  and  swelling  of  the  joints,  it  has  been 
ascribed  to  a  transference  of  morbid  action  consequent  on  the 

'  "  Medico-Chir.  Trans.,"  vol.  xxv. 
2  See  Cap.  VI  of  this  Treatise. 


34  INTRODUCTION. 

subsidence  of  articular  inflammation.  The  advocates  of  this 
doctrine  have  never  attempted  to  explain  in  what  way  such 
translation  takes  place,  and  have  failed  in  showing  that  it 
does  occur  in  any  disorder  known  to  be  truly  local,  yet  they 
have  not  hesitated  to  urge  this  view  in  explanation  of  the 
phenomenon  in  question.  But  even  if  admitted  to  its  fullest 
extent,  it  utterly  fails  in  elucidating  the  symptoms.  For  in 
the  majority  of  instances  where  pericarditis  or  endocarditis  is 
met  with,  there  is  not  the  slightest,  even  temporary,  subsidence 
of  the  external  or  articular  inflammation  ;  and  since  inflam- 
matory action  about  the  heart  is  occasionally  the  earliest,  and 
for  some  time  the  onit/  local  symptom  of  rheumatism,  metas- 
tasis, however  vaguely  understood  and  applied,  must  obviously 
fail  in  clearing  up  the  mystery.  Indeed  the  only  explanation 
appears  to  be  that  the  heart  is  aff"ected  through  the  agency  of 
the  blood,  which  from  some  cause  has  become  unhealthy  and 
irritating  in  its  character.^ 

On  the  other  hand,  the  symptoms  usually  observed  when 
metastasis  does  in  reality  take  place,  when  the  external  inflam- 
mation suddenly  subsides,  and  cardiac  inflammation  simulta- 
neously or  shortly  afterward  commences,  afi"ord  most  striking 
confirmation  of  this  view,  for  they  correspond  precisely  with 
those  observed  under  similar  circumstances  in  cases  where  the 
blood  is  known  to  be  aff"ected.  Rigors  almost  invariably  occur, 
followed  by  increase  in  the  febrile  symptoms;  there  is.  gen- 
erally much  anxiety  of  countenance,  and  evidence  throughout 
of  constitutional  irritation  ;  the  breathing  is  hurried,  the  heart's 
action  accelerated  and  sometimes  irregular,  and  before  the 
symptoms  are  again  locally  fixed,  it  not  unfrequently  becomes 
intermittent.  In  the  mean  time  pains  of  a  spasmodic  character 
occur  in  various  parts  of  the  body ;  hiccough  ensues,  or  vomiting, 
or  perhaps  diarrhoea  supervenes,  which,  though  usually  but 
little  under  the  control  of  medicine,  subsides  together  with 

1  Mons.  Chomel,  among  others,  has  recorded  a  series  of  most  interesting 
observations,  which  tend  to  show,  that  the  internal  inflammations  in  rheuma- 
tism, like  those  of  smallpox,  typhus,  scarlatina,  &c.,  are  referable  to  an  alter- 
ation of  the  animal  fluids,  more  especially  the  blood.  (-'Legons  de  Cliaique 
Medicale,"  1834,  pp.  529-539.) 


INTRODUCTION.  3& 

the    other    phenomena    on    the     re-establishment    of    local 
symptoms.^ 

The  fact  is,  the  doctrine  of  a  poisoned  blood  in  rheumatism, 
though  seldom  fully  recognized  in  theory,  is  tacitly  allowed  full 
weight  in  determining  some  points  in  practice.  When  a  person 
is  suffering  from  the  irritation  of  a  diseased  joint,  the  result  of 
local  injury,  amputation  by  removing  the  part  affected  gets  rid 
of  the  disease,  and  the  accompanying  fever  ;  and  if  rheumatic 
inflammation  were  in  like  manner  a  purely  local  affection,  the 
knife  would  in  that  case  also  effect  a  radical  or  permanent  cure. 
But  no  one  would  propose  the  adoption  of  such  a  remedy  in 
the  case  of  an  inflamed  rheumatic  joint.  The  fruitlessness  of 
such  an  attempt  to  get  rid  of  the  disease  is  at  once  acknowl- 
edged and  acted  on  :  the  blood  itself  being  the  source  of  irri- 
tation, the  mere  removal  of  one  of  the  local  effects  of  that 
irritation  would  obviously  be  ineffectual  in  eradicating  the  com- 
plaint ;  the  inflamed  part  might  be  removed  by  the  scalpel,  but 
there  would  be  nothing  in  its  removal  to  prevent  the  immediate 
occurrence  of  inflammation  in  any  other  part  of  the  body.^ 

If  further  proof  were  required,  I  might  refer  to  the  analogy 
between  rheumatism  and  gout. 

So  curiously  do  these  two  disorders  coincide,  so  imperceptible 
in  certain  cases  is  the  transition  from  the  one  to  the  other, 
that  there  is  no  little  difficulty  in  distinguishing  between  them. 

1  Dr.  Holland  remarks,  ("Medical  Notes  and  Reflections/'  cap.  "Metastasis,") 
"  The  high  state  of  fever,  notable  disturbance  of  the  heart,  and  of  other  func- 
tional derangements  which  constantly  occur  during  the  translation  of  disease, 
and  which  subside  in  great  measure  when  the  symptoms  are  again  locally 
fixed,  is  a  powerful  argument  in  favor  of  a  morbid  matter  in  the  blood  itself.'' 

In  rheumatism,  such  phenomena  are  somewhat  rare,  but  I  have  seen  three 
instances  of  their  occurrence.  One  was  the  case  of  a  boy,  set.  16,  under  my 
own  care  at  St.  George's  Hospital  ;  another,  that  of  a  man  in  King's  Ward, 
under  the  care  of  my  colleague  Dr.  Wilson  ;  and  the  other  that  of  a  lad  admit- 
ted into  Fuller's  Ward,  under  the  care  of  Dr.  Seymour.  In  all  these  cases 
there  was  extreme  vascular  excitement,  with  obstinate  vomiting  followed  by 
diarrhoea. 

2  "  The  heat,  redness,  and  swelling  (of  the  joints)  are  no  more  the  cause  of 
the  constitutional  disturbance  in  acute  rheumatism,  than  the  scarlet-rash  or 
the  smallpox  pustules  of  the  fevers  which  bear  their  respective  names.  They 
are  but  the  partial  expression,  by  impaired  nutrition,  of  a  disorder  that  is  gen- 
eral in  the  system."  (Dr.  Wilson  on  the  "  True  Character  of  Acute  Rheuma- 
tism," "Lancet"  for  1844,  vol.  ii,  p.  192.) 


S6  INTRODUCTION. 

In  both,  an  hereditary  taint  may  frequently  be  traced  ;  in  both, 
the  fever  is  out  of  all  proportion  to  the  extent  and  severity  of 
the  local  mischief;  in  both,  the  joints  are  the  parts  principally 
affected,  and  the  inflammation,  which  is  of  a  peculiar  nature, 
observes  a  remarkable  symmetry  in  attacks  ;  in  both,  internal 
organs  are  often  implicated,  and  in  both,  anomalous  symptoms 
of  a  similar  character  occur  v.'henever  metastasis  takes  place. 
And  not  only  so : — their  aflSnity  becomes  even  more  apparent 
■when  their  history  is  more  closely  and  accurately  examined. 
For  it  is  then  found  that  while  children  of  gouty  parents  are 
peculiarly  subject  to  attacks  of  rheumatism,^  the  offspring  of  a 
rheumatic  stock  no  less  frequently  show  symptoms  of  that 
hybrid  disorder,  rheumatic  gout,  and  in  some  instances  of  une- 
quivocal gout.  Such  a  striking  analogy  between  the  symptoms 
of  the  two  disorders  is  surely  sufficient  to  warrant  our  assum- 
ing a  similarity  of  cause,  and  as  in  gout  the  existence  of  a 
materies  morbi  admits  of  actual  demonstration,^  our  view  is 
confirmed,  as  to  the  existence  of  a  poison  in  the  blood  in  rheu- 
matism. 

Whence  then  does  this  poison  arise  ?  From  what  source  and 
by  what  means  does  the  blood  become  vitiated  ? 

There  are  many  circumstances  in  the  history  of  rheumatism 
which  point  to  its  being  of  constitutional  origin. 

The  earliest  and  most  frequent  victims  of  the  disease,  even 
■when  considering  themselves  in  tolerable  health,  are  apt  to 
experience  symptoms  clearly  denoting  functional  derangement. 
Though  strong,  perhaps,  and  equal  to  much  bodily  exertion, 
they  are  peculiarly  sensitive  to  atmospheric  vicissitudes,  are 
prone  to  perspire,  and  their  perspiration  has  a  sour^  disagree- 

'  "  Rheumatism  is  undoubtcdlj'  nearly  allied  to  gout,  and  tits  of  it  have  been 
more  common  in  children  born  of  gouty  parents."  (Dr.  Heberden's  "  Com- 
mentaries," p.  399.) 

'•'  Dr.  Garrod  has  demonstrated  by  chemical  analysis  the  existence  of  uric 
acid  in  the  blood  of  gouty  patients,  and  its  absence  from  the  blood  in  rheuma- 
tism.    (See  "  Med.-Chir.  Trans.,"  vols,  xxxi  and  xxxvi.) 

3  A  rheumatic  gentleman  not  long  since  assured  me,  that  he  is  unable  to 
carry  a  knife  or  other  steel  instrument  in  his  pocket,  in  consequence  of  its 
becoming  rusty  from  the  acidity  of  the  perspiration. 


INTRODUCTION.  37 

able  odor,  while  their  urine,  though  usually  clear  when  passed, 
not  unfrequently  deposits,  on  cooling,  a  red  brick-dust  sedi- 
ment, a  sediment  of  the  lithates  and  lactates.  So  constantly 
are  these  symptoms  associated  with  a  tendency  to  rheumatism, 
that  they  have  been  recognized  as  indicative  of  a  "  rheumatic 
diathesis,"  or,  in  other  words,  of  a  case  of  constitution  pecu- 
liarly prone  to  the  incursion  of  rheumatism.  And  it  has  been 
observed  that  in  persons  so  predisposed,  the  heart  is  irritable, 
and  prone  to  take  on  inflammatory  action,  and  that  even  when 
it  is  not  attacked  by  inflammation,  its  nutrition  is  apt  to  become 
perverted,  its  valves  more  or  less  diseased,  and  its  walls  thick- 
ened in  consequence.  Moreover,  erratic  pams  ensue  on  the 
slightest  derangement  of  the  general  health,  and  are  relieved 
not  by  any  specific  treatment,  but  by  shower-baths,  or  tonics, 
or  whatever  tends  to  improve  the  general  health. 

Again,  it  has  been  remarked,  that  whereas  certain  persons 
are  subject  to  rheumatism,  others  under  precisely  the  same  cir- 
cumstances, of  the  same  age  and  sex,  living  in  the  same  locality, 
sometimes  even  in  the  very  same  house,  exposed  to  the  same 
atmospheric  vicissitudes,  and  following  the  same  pursuits, — 
placed,  in  short,  in  a  precisely  similar  position  with  regard  to 
external  influences, — remain  perfectly  free  from  the  disease. 

And  again,  that  certain  persons,  who  during  the  whole  of 
their  previous  existence  have  lived  in  perfect  immunity  from 
the  disease,  become  suddenly  tormented  with  it  on  changing 
their  mode  of  living,  or  from  some  less  obvious  cause,  while 
others  who  had  long  labored  under  this  affliction,  got  rid  of  their 
troublesome  enemy  in  an  equally  remarkable  and  mysterious 
manner. 

From  these  general  facts  alone  it  might  be  inferred,  that  the 
materies  morbi  on  which  the  symptoms  of  rheumatism  depend, 
is  generated  under  certain  circumstances  in  the  system,  and  is 
so  generated  as  a  result  of  some  obscure  constitutional  peculi- 
arity, some  particular  form  of  mal-assimilat'.on. 

But  there  are  other  facts  which  tend  directly  to  the  same 
conclusion.  The  disease  generally  makes  its  appearance  in 
those  subject  to  its  invasion,  whenever  the  system  is  lowered  or 


38  INTRODUCTION. 

deranged.  It  is  so  frequent  an  attendant  on  disordered  condi- 
tions of  the  uterine  system,  that  its  intimate  connection  with 
retained  uterine  secretions  has  been  suggested  by  Dr.  Todd^ 
and  other  observers.  M.  ChomeP  has  been  struck  with  the 
frequency  of  its  occurrence  after  excessive  lactation,  after  inor- 
dinate indulgence  of  the  sexual  desires,  and  during  tedious 
recoveries  from  fever  f  and  all  who  have  carefully  studied  the 
disease  in  the  vast  field  of  observation  afforded  by  the  wards  of 
our  public  hospitals,  must  have  remarked  how  constantly  its 
attacks  have  been  preceded  by  functional  derangement. 

The  important  observation  of  Sir  John  Pringle,*  that  rheu- 
matism is  more  prevalent  at  the  commencement  of  a  campaign 
and  shortly  after  return  to  garrison,  than  at  any  other  period  of 
a  soldier's  career,  comes  in  perfect  confirmation  of  these  inter- 
esting gleanings  from  civil  life.  For  nothing  can  be  more  in 
accordance  with  experience,  than  that  temporary  derangement 
of  the  system  should  be  produced  by  the  entire  change  of  life 
which  a  soldier  undergoes  when  first  called  into  the  field,  and 
when  again,  after  active  service,  he  returns  to  the  close  con- 
finement of  the  barrack.  Whereas,  under  no  other  supposition 
is  it  possible  to  account  for  the  prevalence  of  the  disease  at 
the  very  times  when  the  soldiers  are  best  equipped,  most  pro- 
tected against  atmospheric  vicissitudes,  and  free  from  the 
many  privations  and  the  exposure  inseparable  from  active 
service. 

There  are  other  facts  of  a  different  character  which  bear 
just  as  strongly  on  the  solution  of  this  question.  It  has  now 
been  established  beyond  dispute,  that  rheumatism,  like  gout,  is 
distinctly  hereditary.^  And  if  the  general  law  of  hereditary 
affections,  as   Sir   Henry   Holland    asserts,^  be   that   so   ably 

'  On  "  Rheumatism,"  p.  149. 

*  "  Le(;ons  de  Clinique  Medicale,"  torn,  ii,  p.  151. 

*  "  Enfin  on  le  voit  souvent  se  manifester  pendant  la  faiblesse  qui  occupe 
toujours  la  convalescence."     (Op.  cit.,  p.  467.) 

*  "  Observations  on  Diseases  of  the  Army,"  part  I,  cap.  iii  and  iv  ;   part  II, 
cap.  i ;  part  III,  cap.  iii. 

*  See  Cap.  ii,  p.  32. 

6  "  Medical  Notes  and  Reflections,"  cap.  on  "  Hereditary  Affections." 


INTRODUCTION.  39 

developed  by  Dr.  Prichard,  viz. :  that  "  all  original  connate 
bodily  peculiarities  tend  to  become  hereditary,  while  changes 
in  the  organic  structure  of  the  individual,  from  external  causes 
during  life,  end  with  him,  and  have  no  influence  on  his  pro- 
geny," it  follows  that  rheumatism,  being  an  hereditary  disease, 
must  be  in  its  nature  constitutional. 

Perhaps  the  strongest  proof  of  its  constitutional  origin,  is  to 
be  found  in  the  variable  and  often  long  duration  of  the  dis- 
order. For  unless  it  be  admitted  that  the  materies  morbi  may 
be  generated  de  novo  in  the  system,  the  long  continuance  and 
frequent  recurrence  of  the  articular  symptoms  are  altogether 
inexplicable.  If  the  disease  were  dependent  on  a  poison  intro- 
duced into  the  system  from  without,  it  should  manifest  some 
of  the  peculiarities  of  disorders  which  acknowledge  such  an 
origin ;  it  should  occur  more  or  less  periodically  or  epidem- 
ically :  it  should  run  a  someAvhat  regular  and  definite  course, 
and  should  confer  upon  a  person  who  has  once  experienced 
its  attacks,  an  immunity  from,  or  partial  protection  against, 
its  future  invasion.  But  rheumatism  is  always  met  with 
sporadically ;  its  career  is  remarkably  variable  and  uncer- 
tain ;^  and  so  far  from  a  well-developed  attack  affording  pre- 
tection  against  its  future  invasion,  it  is  generally  believed  that 
a  person  who  has  once  been  subjected  to  its  influence,  is  pecu- 
liarly liable  afterward  to  its  invasion.  And  if,  which  is  the 
only  other  supposition,  the  disease  were  dependent  on  the 
irritation  of  a  matter  resulting  from  temporary  suspension  of 
the  skin's  function,  it  should  subside  on  the  re-establishment 
of  a  free  cutaneous  action  ;  the  more  so,  as  in  a  well-developed 
attack,  the  perspiration  is  constant  and  excessive. 

As,  then,  it  appears  impossible  to  avoid  the  conclusion  that 
the  materies  morbi  is  generated  in  the  system  as  a  product  of 
mal-assimilation,  or  faulty  metamorphic  action,  the  next  points 
for  consideration  are  those  which  serve  to  indicate  its  nature. 

1  In  one  case,  it  runs  a  short,  acute,  and  regular  course;  in  another,  the 
patient  experiences  relapses,  in  each  of  whi'',h,  the  original  symptoms  not 
unfrequently  recur  with  all  their  former  virulence  ;  while,  in  a  third  case,  the 
disorder  lingers  on  for  months  in  a  semi-acute  form,  aggravated  by  irregularly 
periodical  exacerbations. 


40  INTRODUCTION. 

A  suggestion  was  thrown  out  by  Dr.  Prout,  and  has  been 
adopted  and  enlarged  upon  by  Dr.  Todd  in  his  Croonian 
Lectures,  that  all  the  phenomena  of  the  disease  are  referable  to 
the  presence  of  lactic  acid,  which  is  developed  too  freely  in 
the  system  in  consequence  of  imperfect  assimilation,  and  accu- 
mulates in  the  blood  by  reason  of  defective  cutaneous  action. 

"It  is  no  wonder,"  says  Dr.  Todd,  "that  as  lactic  acid  is 
imperfectly  excreted  through  its  natural  channels,  in  conse- 
quence of  the  influence  of  cold  in  checking  perspiration,  and 
is  too  freely  developed  in  the  alimentary  canal,  it  should 
accumulate  in  the  blood  and  become  eliminated  at  every  point. 
Moreover,  the  long  continuance  of  the  causes  which  produce 
the  defective  cutaneous  secretion  and  the  deranged  gastric 
one,  will  give  rise  to  the  development  of  lactic  acid  in  the 
secondary  processes  of  assimilation,  thus  infecting  the  blood 
from  every  source,  and  tending  to  perpetuate  the  diathesis." 

More  recently  this  view  has  been  somewhat  modified,  and 
has  received  more  complete  and  satisfactory  elucidation,  from 
Dr.  Headland,  in  his  valuable  treatise  on  the  action  of  med- 
icines.^ After  referring  to  the  commonly  received  opinion, 
that  before  the  starch  of  the  food  can  be  applied  to  the  main- 
tenance of  the  animal  heat,  it  has  to  be  converted  into  lactic 
acid,  which  then  combines  with  oxygen  to  form  carbonic  acid 
and  water,  in  which  form  it  is  thrown  out  of  the  system  by  the 
lungs,  he  points  out  how  anything  which  interferes  with  this 
oxidation  of  lactic  acid,  must  lead  to  its  excessive  accumu- 
lation in  the  system.  He  thus  suggests  that  simple  "  want  of 
vital  energy  or  nervous  force,"  or  "a  failure  of  some  natural 
principle  which  is  gifted  with  the  control  and  direction"  of  the 
chemical  changes  in  the  blood ;  or,  in  short,  any  disturbing 
cause,  of  whatever  nature,  which  may  tend  to  prevent  the  nor- 
mal series  of  changes  from  taking  place,  may  lead  to  the 
accumulation  of  lactic  acid  in  the  system,  and  so  may  prove 
the  accidental  or  exciting  cause  of  rheumatism.  And  he  leaves 
it  to  be  inferred  that  the  disease  is  usually  due  to  such  causes, 
rather  than  to  the  non-excretion  of  lactic  acid  by  the  skin,  or 

'  Headland  "  On  the  Action  of  Medicines,"  pp.  85-"j0. 


INTRODUCTION.  41 

to  its  excessive  formation  in  the  primary  or  secondary  processes 
of  assimilation. 

My  own  opinion  is  strongly  in  favor  of  this  view,  which 
alone  of  all  the  theories  hitherto  propounded,  is  reconcilable 
with  the  admitted  facts,  that  rheumatism  may  occur  under  a 
great  variety  of  circumstances,  and  at  times  when  the  digestive 
organs  are  but  little  deranged  ;  that  it  may  arise  without  any 
exposure  to  cold,  or  arrest  of  the  skin's  function  ;  that  it  con- 
tinues after  the  skin's  action  is  re-established ;  and  that  it  may 
be,  and  often  is,  occasioned  by  influences  prejudicial  to  the 
general  health. 

It  is  true  that  the  poison  which  gives  rise  to  rheumatism  has 
not  as  yet  received  actual  demonstration,  but  many  facts  con- 
duce to  a  belief  in  its  identity  with  some  natural  excretion  of 
the  skin.  In  advanced  life,  when,  from  want  of  energy  in  the 
system,  the  skin's  action  is  readily  interfered  with,  pain  or 
stiffness  is  so  constantly  produced  by  a  draught  of  cold  air, 
and  subsides  so  soon  after  reaction  has  taken  place,  that  we 
are  bound  to  admit  its  intimate  connection  with  temporary 
suspension  of  cutaneous  action.*  Moreover,  rheumatism  is  so 
common  among  persons  suffering  from  renal  disease,  and  other 
complaints  accompanied  by  a  harsh,  inactive  condition  of  the 
skin,  that  it  is  impossible  not  to  connect  its  appearance,  under 
such  circumstances,  with  the  cessation  of  free  cutaneous 
transpiration. 

The  means  which  nature  adopts  for  its  relief,  and  the  cir- 
cumstances which  attend  its  imperfect  development,  are  also 

'  This  instructive  fact  may  appear  at  first  sight  to  countenance  the  hypoth- 
esis of  cold  as  the  universal  cause  of  rheumatism.  But,  in  rcialily,  ic  will 
bear  no  such  construction.  For  although  the  poison  which  produces  the  local, 
symptoms  of  the  disease  is  in  all  instances  the  same,  it  is  necessarily  small 
and  definite  in  quantity  when  attributable  solely  to  checked  perspiration,  and; 
the  symptoms,  therefore,  to  which  it  gives  rise  must,  and  do  gradually  subside 
from  the  time  when  the  function  of  the  skin  is  re-established.  But  it  is  noto- 
rious, that  in  rheumatism,  the  development  of  free  cutaneous  action  has  seldom 
much  immediate  influence  in  arresting  the  symptoms.  This  arises  from  the 
fact,  that  the  poison  in  these  cases  is  constantly  generated  de  novo  in  the 
system,  and  its  production  being  dependent  on  many  contingent  circumstances, 
its  amount  is  indefinite,  and  the  symptoms  therefore  produced  through  its 
agency  are  uncertain  and  variable  in  duration. 
4 


42  INTRODUCTION. 

suggestive  of  a  relationship  between  rheumatism  and  cutaneous 
secretion.  No  sooner  is  a  person  attacked  by  the  disease  than 
excessive  perspiration  is  set  up,  as  if  with  the  view  of  getting 
rid  of  some  peccant  matter,  and  the  secretion  is  most  profuse 
at  the  very  part  where  local  inflammation  is  taking  place. ^  If 
the  perspiration  be  checked,  or  take  place  irregularly  or  im- 
perfectly, the  disease  is  protracted,  and  is  rarely  got  rid  of  until 
free  cutaneous  action  has  been  re-established.  It  is  probable, 
therefore,  that  in  lactic  acid  we  have  discovered  the  actual  ma- 
teries  morbi.^  Be  this  as  it  may,  the  ordinary  symptons  of  the 
disease,  no  less  than  the  history  of  its  rarer  modifications,  are 
calculated  to  point  to  some  excretion  of  the  skin  as  the  imme- 
diate cause  of  rheumatic  inflammation. 

One  other  point,  in  connection  with  this  subject,  is  well  de- 
serving of  attention,  I  mean  the  specific  nature  of  the  poison 
which  constitutes  the  essence  of  rheumatism.  If  the  matter, 
which  excites  rheumatic  inflammation  and  produces  the  other 
symptoms  of  the  disease,  be  in  all  cases  the  same,  or,  in  other 
words,  of  a  peculiar  and  specific  character,  it  follows  that 
nothing  can  give  rise  to  rheumatism,  properly  so  called,  unless 
it  have  the  power,  either  directly  or  indirectly,  of  producing 
this  poison  in  the  system.  No  point  in  the  whole  course  of 
medical  inquiry  is  more  fully  established,  than  that  diff'erent 
poisons  have  separate  modes  of  action,  and  produce  each  its 
own   peculiar  efi'ect.^      What  weight,  for  instance,  would    be 

1  I  am  not  aware  of  having  met  with  this  remark  in  books :  and  as  the  seat 
of  the  inflammation  is  often  the  driest  spot  in  the  body,  its  accuracy  may,  per- 
haps, be  questioned.  It  may  be  well,  therefore,  to  point  out  the  source  of  this 
apparent  contradiction,  which  arises  from  the  different  condition  of  the  part  at 
different  periods  of  the  disease.  When  a  spot  is  just  beginning  to  be  painful, 
then  it  is,  before  the  circulation  is  much  impeded,  that  excretion  will  there  be 
found  so  abundant;  whereas,  if  no  obscrvaiion  be  made  until  progressing  in- 
flammation has  greatly  retarded  the  circiilatiou,  excretion  from  the  part  is 
almost  necessarily  arrested. 

*  Dr.  C.  J.  B.  Williams,  among  others,  expresses  his  belief  in  the  origin  of 
rheumatism  from  a  poison,  probably  lactic  acid,  in  the  system.  ("  Principles 
of  Medicine,"  p.  116.) 

"  The  relative  bearing  of  cause  and  effect  is  the  grand  physical  principle 
which  alone  makes  medicine  worthy  of  our  study,  for  if  it  be  supposed  that 
agents  capable  of  acting  in  the  human  body  have  not  each  their  definite  mode 


INTRODUCTION.  43 

attached  to  the  testimony  of  a  man,  who  stated  that  he  had 
known  the  poison  of  glanders  give  rise  to  liydrophobia,  or  that 
of  measles  to  small-pox  ?  Yet  in  what  disorder  are  the  gene- 
ral phenomena  more  striking,  and  the  local  effects  more  singu- 
lar and  remarkable,  than  in  acute  rheumatism  ?  A  peculiar 
and  specific  character  is  so  clearly  stamped  on  this  disease,  that 
no  one  will  attempt  to  question  it ;  few  on  due  consideration 
will  deny  its  dependence  on  a  poisonous  matter  in  the  system ; 
all,  therefore,  ought  to  agree  as  to  the  specific  nature  of  that 
poison.  Bat,  in  defiance  of.  those  very  laws,  the  due  apprecia- 
tion of  which  alone  makes  any  study  a  science,  rheumatism  has 
been  referred  to  a  dozen  different  causes,  and  inferentially  at 
least  to  as  many  different  poisons.  It  has  been  attributed  to 
checked  or  deficient  perspiration,  to  exposure  to  cold  or  to 
malarious  exhalations,  to  indigestion  and  imperfect  assimila- 
tion, to  defective  or  perverted  uterine  action,  to  the  ill  perform- 
ance of  the  renal  functions,  to  plethora,  and  to  debility  ;  to  one 
cause  or  to  another,  as  the  history  of  the  case  or  the  appearance 
of  the  patient  may  at  first  sight  have  seemed  to  warrant. 
Now  I  will  venture  to  assert,  that  although  a  dozen  different 
predisposing  causes  may  tend  to  the  production  of  the  rheu- 
matic virus  in  the  system,  and  a  dozen  different  exciting  causes, 
may  each  separately  promote  its  action  and  give  rise  to  the 
immediate  development  of  the  symptoms,  yet  that  the  poison 
which  is  to  produce  a  regular  and  determined  disorder  like 
acute  rheumatism,  must  be  invariably  the  same,  must  be  m 
itself  peculiar, — specific,  as  giving  rise  to  a  specific  affection. 

Dr.  Todd  has  suggested,  that  disordered  uterine  secretions 
may  be  an  occasional  cause  of  rheumatism.  lie  conceives 
"that  the  secretions  of  the  uterus,  if  of  an  unhealthy  char- 
acter, and  not  duly  thrown  off,  may  be  absorbed  into  the  cir- 
culation and  contaminate  the  blood,  producing  symptoms  of 

of  action,  we  caa  neither  determine  tlie  seat  and  course  of  any  given  disorder 
nor  judge  of  tlie  operation  of  remedies  ;  whereas,  if  the  definite  action  of  causes 
be  allowed,  we  arc  enabled  to  determine,  within  certain  limits,  the  course, 
symptoms,  and  pathological  phenomena  which  result  from  the  action  of  any 
known  agent."  (Dr.  Williams's  Introduction  to  a  "  Treatise  on  Morbid 
Poisons.") 


44  INTRODUCTION. 

greater  or  less  urgency,  according  to  the  nature  and  quantity 
of  the  morbid  secretion  which  may  have  been  absorbed."' 

Now,  I  am  ready  to  admit,  that  nothing  so  easily  deranges 
the  whole  female  economy,  produces  more  perverted  actions  in 
the  system,  and  therefore  tends  more  directly  to  the  genera- 
tion of  the  peccant  matter  of  rheumatism,  than  does  disordered 
uterine  action.  But  if  a  certain  product  of  faulty  assimilation 
be  at  once  the  essence  and  cause  of  rheumatism,  (and  Dr.  Todd 
himself  has  adduced  powerful  arguments  in  favor  of  such  a 
supposition,)  then  the  retained  or  altered  secretions  of  the 
uterus  cannot  give  rise  to  the  same  phenomena,  unless  they  be 

1  "  On  Rheumatism,"  p.  149.  In  support  of  his  position,  Dr.  Todd  cites  a 
case  in  which  a  state  of  protracted  araenorrhcca,  painful  menstruation,  and  dis- 
ordered uterine  function  was  entirelj-  relieved  by  the  occurrence  of  a  paroxysm 
of  acute  rheumatism.  The  individual  in  whom  these  symptoms  occurred  was 
a  country  girl,  23  years  of  age,  who  had  come  to  town  about  twelve  months 
previously.  While  in  the  country  she  had  exhibited  well-marked  symptoms 
of  a  rheumatic  tendency,  having  suffered  from  wandering  rheumatic  pains  i 
and  when  she  came  to  London  the  rheumatic  symptoms  increased,  her  health 
began  to  fail,  and  after  a  time  the  catamenia  ceased.  In  about  si.x  weeks  after 
this  she  began  to  suffer  from  severe  uterine  pains,  which  continued  for  about 
five  months,  when  an  attack  of  acute  rheumatism  supervened,  and  all  her 
symptoms  disappeared. 

The  case  is  interesting,  from  the  clear  evidence  adduced  of  the  protracted 
existence  of  the  rheumatic  diathesis,  from  the  lengthened  premonitory  indica- 
tions of  its  ultimate  development,  and  from  the  clear  proof  afforded,  that  the 
uterus  may  be  affected  by  the  irritation  of  the  rheumatic  poison  as  well  as  the 
heart  and  other  parts  of  the  body.  But  the  inferences  drawn  from  it  by  Dr. 
Todd  appear  to  me  inconsistent  with  the  recorded  facts.  So  far  from  dis- 
ordered uterine  secretion  having  been  the  cause  of  the  rheumatic  symptoms, 
clear  evidence  is  offered  of  a  strong  rheumatic  tendency  at  a  time  when  the 
uterine  functions  were  in  no  way  disordered,  for  she  had  suffered  from  rheu- 
matic pains  in  the  country  when  she  was  otherwise  in  good  health,  and  her 
health  had  begun  to  fail  before  the  catamenia  ceased.  My  interpretation  of 
the  case  would  be,  that  before  coming  to  town  she  had  acquired  a  strong  rheu- 
matic tendency,  and  that,  when  after  reaching  London,  her  general  health 
gave  way,  the  functions  of  the  uterus  became  disturbed,  the  monthly  periods 
eeased,  and  the  rheumatic  virus,  which  is  peculiarly  prone  to  affect  any  part 
which  is  functionally  deranged,  attacked  the  womb,  and  gave  rise  to  the  ute- 
rine pain  and  its  attendant  symptoms.  The  pains  she  suffered  were  truly 
rheumatic,  and  were  to  be  cured,  as  Dr.  Locock  has  suggested,  in  similar  cases, 
by  guaiacum,  colchicum,  or  whatever  may  tend  to  relieve  the  rheumatism,  and 
in  this  case  were  actually  relieved  by  the  full  development  of  acute  rheumatism, 
and  the  consequent  elimination  of  the  rheumatic  poison,  the  source  of  all  her 
previous  suffering. 


INTRODUCTION.  45 

identical  in  nature  with  this  said  product  of  mal-assimilation ; 
and  to  this,  analogy  would  lead  us  to  demur. 

But  although  a  specific  poison,  generated  in  the  system  as 
the  result  of  faulty  raetamorphic  action,  is  the  primary  or  prox- 
imate cause  of  rheumatism,  and  constitutes  the  actual  materies 
morbi,  yet  many  agencies  may  conduce  to  the  formation  of  the 
poison  and  to  its  retention  in  the  system,  and  many  circum- 
stances may  render  the  body  peculiarly  susceptible  of  its  influ- 
ence. These  are  the  predisposing  and  exciting  causes  of  the 
disease.  Of  all  such  causes,  an  inherited  rheumatic  taint  is 
unquestionably  the  strongest.  It  exerts  its  influence,  slowly 
perhaps,  but  surely  ;  and  few  who  have  succeeded  to  this  unfor- 
tunate inheritance,  but  at  some  period  of  their  life  exhibit 
symptoms  of  that  peculiar  state  of  system  which  has  been 
recognized  under  the  title  of  the  "rheumatic  diathesis." 
Thus,  many  varieties  of  functional  disturbance,  many  forms  of 
hepatic  and  uterine  derangement,  and  those  diseases  of  the 
kidney  connected  with  albuminous  urine,^  by  impairing  the  gen- 
eral health,  perverting  the  functions  of  nutrition  and  secretion, 
and  interfering,  more  or  less,  with  the  skin's  action,  may  be- 
come active  agents  in  the  production  of  this  predisposition. 
Their  morbid  effects  are  not  confined  to  the  liver,  the  uterus, 
or  the  kidneys  :  one  part  of  the  animal  economy  hinges  so 
closely  on  the  other,  that  local  mischief  occasions  general  dis- 
turbance, and  under  certain  circumstances  appears  to  induce  a 
state  of  system  favorable  to  the  generation  of  rheumatic  poison ; 
a  state  of  system  arising,  be  it  observed,  not  as  a  direct  and 
immediate  consequence  of  suspended  secretion,  but  as  a  sequel 
of  perverted  function  gradually  taken  on  by  the  system  gen- 
erally, in  consequence  of  imperfect  or  morbid  local  action.^ 

•  This  is  a  powerful  predisposing  cause  of  the  disease,  inasmuch  as  not  only 
is  the  skin's  action  interfered  with,  but  the  diseased  organs  are  unable  to  act 
vicariously,  and  so  to  assist  in  eliminating  the  poison. 

2  The  phenomena  of  gonorrhoea  afford  an  admirable  example  of  how  local 
diseases  may  gradually  give  rise  to  general  derangement  of  the  system,  and  so 
to  the  production  of  the  peccant  matter  of  rheumatism.  So  constantly  is 
rheumatism  associated  with  gonorrhoea,  that  many  rheumatic  persons,  on  con- 
tracting that   disease,  can  predict  with  amazing  accuracy  the  accession  of 


46  INTRODUCTION. 

In  like  manner  cold,  by  exercising  a  depressing  influence  on 
the  system,  and  thus  producing  functional  derangement,  may 
contribute  largely  to  the  generation  of  the  rheumatic  poison, 
and  so  may  damp  and  malarious  exhalations.  Excessive  venery 
and  long-continued  debauchery  are  in  the  same  way  frequently 
productive  of  rheumatism,  and  so  is  immoderately  protracted 
lactation.  Many  a  woman  suffers,  soon  after  her  confinement, 
if  followed  by  great  constitutional  exhaustion,  or  as  the  reward 
of  her  folly,  in  inordinately  protracting  the  period  of  suckling. 
Chomel,  who  observed  the  frequency  of  the  disease  shortly  after 
delivery,  refers  its  appearance,  under  such  circumstances,  to 
the  sudden  suppression  of  the  lochial  discharge.  Such  an  ex- 
planation, however,  does  not  hold  good.  It  is  diflBcult  to  con- 
ceive how  the  lochia  can  have  any  connection  with  rheumatism, 
except  as  producing  functional  derangement,  and  so  possibly 
tending  to  favor  the  development  of  the  rheumatic  virus  in  the 
system ;  and  I  have  myself  seen  several  cases  in  which  the 
disease  did  not  appear  until  some  time  after  the  lochial  dis- 
charge had  naturally  and  entirely  ceased ;  until,  in  fact,  im- 
paired nutrition  had  begun  to  follow  on  the  wear  and  tear 
sustained  by  the  constitution  during  delivery,  or  during  lacta- 
tion carried  beyond  the  patient's  strength. 

These,  then,  and  many  other  instances  Avhich  might  be  quoted, 
may  be  fairly  included  under  the  general  expression,  that  any- 
thing which  disturbs  the  general  health,  and  gives  rise  to  a  state 
of  impaired  assimilation,  becomes,  under  certain  circumstances, 
a  predisposing  cause  of  rheumatism.^  The  only  way,  there- 
fore, of  preventing  or  counteracting  it,  is  by  noting  the  earliest 

rheumatic  inflamraation  of  their  joints,  and  not  unfrequently  of  inflammation 
of  the  conjunctiva,  such  as  is  apt  to  accompany  rheumatism  in  unhealthy  or 
cachectic  persons. 

'  I  am  glad  to  quote,  in  confirmation  of  my  opinion,  some  admirable  remarks 
by  Dr.  Taylor,  of  Huddersfield.  ''  I  believe,"  he  says,  "  the  really  efficient 
cause,  to  be  such  a  change  in  the  constitution  of  the  body,  chiefly,  perhaps,  of 
the  fluids,  as  is  more  or  less  slowly  induced,  under  the  influence  of  circum- 
stances unfavorable  to  health,  but  often  operating  imperceptibly,  and  discov- 
ered only  by  very  careful  investigation ;  I  allude  more  particularly  to  impro- 
prieties, not  necessarily  gross  ones,  in  diet,  clothing,  or  labor,  and  to  undue 
habitual  exposure  to  cold  or  damp,  or  anxiety  of  mind,  as  well  as  to  other 
agencies  which  gradually  undermine  the  health."  ("Med,-Chir.,"  vol.  xxviii, 
pp.  462-3.) 


INTRODUCTION.  47 

symptoms  of  local  disturbance,  and  taking  active  measures  to 
prevent  its  continuance,  by  carefully  attending  to  the  general 
health,  and  lastly,  as  the  skin  is  the  peculiar  emunctory  of  the 
poison,  by  promoting  free  cutaneous  action. 

The  exciting  causes  of  the  disease  are  extremely  numerous, 
but  not  being  peculiar  to  rheumatism,  they  hardly  call  for 
comment  or  observation.  Suffice  it  to  say  that  when  the  rheu- 
matic poison  is  present  in  the  system,  any  disturbing  circum- 
stance, even  of  temporary  duration,  such  as  over-fatigue, 
anxiety,  grief,  or  anger,  by  rendering  the  system  more  suscept- 
ible of  its  influence,  may  prove  the  accidental  or  exciting  cause 
of  the  disease,  and  that  exposure  to  cold  or  to  atmospheric 
vicissitudes  is  almost  certain  to  induce  an  attack. 

The  more  the  history  of  rheumatism  is  studied,  the  more 
closely  and  carefully  its  details  are  examined,  the  more  obvious 
does  it  become  that  the  disease  does  not  result  from  the  local 
agency  of  cold.'  But  when  after  long-continued  exposure, 
cold  begins  to  exercise  a  depressing  influence  on  the  system,  it 
at  once  opens  the  door  to  mal-assimilation,  and  thereby,  if  a 
rheumatic  tendency  exist,  to  the  formation  of  the  rheumatic 
poison  ;  and  when  that  poison  is  present  in  the  system  it  assumes 
a  further  noxious  potency ;  it  then  not  only  exercises  a  depress- 
ing influence  on  the  system,  and  thereby  renders  it  more  sus- 
ceptible of  the  irritation  of  the  poison,  but  by  checking  free 
cutaneous  action  it  stops  the  natural  outlet  of  the  morbific 
agent,  promotes  its  accumulation  in  the  system,  and  thereby 
tends  directly  to  the  development  of  the  disease. 

Thus  it  would  appear  that  cold  and  other  external  agencies 
are  only  predisposing  and  exciting  causes  of  rheumatism,  and 
that  the  primary,  proximate,  or  essential  cause  of  the  disease, 
is  the  presence  of  a  morbid  matter  in  the  blood,  generated  in 

'  '•  Cold  is  a  frequent  cause  of  rheumatic  fever,  and  produces  its  effects  on 
the  joints  by  interference  with  the  general  business  of  nutrition,  not  by  local 
influences  directly  prejudicial  to  their  structure.  These  organs  are  never  more 
carefully  protected  from  cold  than  during  the  great  heats  and  sweats  of  the 
rheumatic  fever,  yet  one  large  joint  after  another  becomes  inflamed  in  sequel 
of  the  constitutional  disorder  during  a  period  of  time  extending,  it  may  be, 
over  weeks,  from  the  invasion  of  the  joint  first  attacked  to  that  of  the  last." 
("  On  the  true  Character  of  Acute  Rheumatism,"  by  Dr.  J.  A.  Wilson,  "  Lan- 
cet," 1844,  p.  193.) 


48  INTRODUCTION. 

the  system  as  the  product  of  a  peculiar  form  of  mal-assim- 
ilation — of  vicious  metamorphic  action.  This  poison  it  i? 
which  excites  the  fever/  and  produces  all  the  pains  and  local 
inflammations  which  are  often  found  associated  in  an  attack 
of  rheumatism.  If  the  rheumatic  virus  be  present  in  small 
quantity  only,  it  may  cause  little  more  than  wandering  pains 
in  the  limbs,  and  may  scarcely  induce  any  perceptible  fever, 
while  if  it  exist  in  larger  quantities,  it  rarely  fails  to  cause 
febrile  disturbance,  and  excite  inflammation  in  various  parts 
of  the  body.  In  that  respect,  however,  its  effects  are  found  to 
vary  in  different  cases.  Sometimes,  though  it  cause  great 
febrile  excitement,  its  local  agency  may  be  confined  to  the 
production  of  external  articular  inflammation  ;  at  others  it 
may  fail  to  produce  arthritis,  but  may  give  rise  to  acute 
inflammation  of  the  heart ;  and  at  others,  again,  carditis  may 
be  only  one  out  of  several  internal  inflammations  which  it  sets 
up  coincidently  with  extensive  articular  mischief.  Moreover, 
there  appear  good  grounds  for  believing  that,  as  in  some  cases 
it  gives  rise  to  excessive  febrile  disturbance  for  days  prior  to 
the  accession  of  articular  inflammation,  and  repeatedly  without 
exciting  inflammation  of  the  heart,  so  in  certain  instances  it 
may  excite  the  peculiar  train  of  symptoms  whereby  rheumatic 
fever  is  characterized,  without  producing,  from  first  to  last,  the 
slightest  concurrent  local  inflammation,  whether  of  the  joints, 
or  of  the  heart,  or  any  other  organ. ^ 


'  The  fever  in  some  instances  may  be  aggravated  by  the  local  inflam- 
mations, but  it  is  essentially  independent  of  them,  and  is  frequently  well 
developed  long  before  their  commencement. 

^I  have  met  with  several  instances  in  which  the  development  of  rheumatic 
fever  has  been  complete,  and  in  which,  nevertheless,  the  articular  and  other 
local  symptoms  have  been  slight  and  evanescent.  One  case  of  this  sort  is 
reported  in  Cap.  VIII  of  this  work.  In  another,  in  which  no  articular  inflam- 
mation occurred  until  the  eighth  day  of  the  attack,  the  fever  was  from  the  first 
most  severe  and  characteristic.  Dr.  John  Taylor  has  reported  similar  instances, 
and  Dr.  Graves  ("Clinical  Medicine,"  p.  914)  has  met  with  "several  well- 
marked  cases  of  individuals  liable  to  rheumatic  fever,  and  who  had  previously 
8uff"ered  from  attacks  of  fever  with  arthritis  in  the  usual  form,  who  subse- 
quently, on  exposure  to  cold,  were  seized  with  symptoms  of  pyrexia,  which  in 
intensity,  duration,  and  every  other  particular  were  identical  with  these  former 
fevers,  save  and  except  that  from  beginning  to  end,  not  a  single  joint  was 
inflamed." 


CHAPTER  II. 

ON  THE  UEREDITARY  CHARACTER  OF  RHEUMATISM. 

In  the  Introductory  Chapter,  I  have  directed  attention  to 
a  certain  state  of  constitution  in  which  a  strong  tendency  to 
rheumatism  exists  as  a  sequel  of  disordered  or  perverted  nutri- 
tion. To  determine  the  conditions  which  favor  the  production 
of  such  a  state,  to  ascertain  the  laws  which  govern  its  develop- 
ment, and  to  discover,  if  possible,  some  means  of  checking  or 
arresting  its  progress,  is  a  matter  of  some  importance  ;  and  I 
will,  therefore,  endeavor  to  bring  together  various  circum- 
stances which  appear  to  throw  some  light  on  the  subject. 

One  of  the  most  suggestive,  and  for  practical  purposes  the 
most  important,  is  the  hereditary  character  of  the  disease 
under  consideration.  Rheumatism,  like  gout,  is  distinctly 
hereditary.  From  father  to  son  its  seeds  are  transmitted  and 
bear  fruit  in  exact  proportion  to  the  degree  in  which  circum- 
stances prove  favorable  to  their  growth.  In  those  persons 
who  are  exposed  to  atmospheric  vicissitudes,  and  pay  little 
heed  to  their  general  health,  the  soil  is  congenial  and  admi- 
rably adapted  for  the  full  development  of  the  disease ;  mal- 
assimilation  is  very  likely  to  occur;  the  skin  performs, its 
function  irregularly  ;  and  the  poison  thus  generated  and 
retained  in  the  system  can  hardly  fail  to  bear  fruit  to  perfec- 
tion. Not  only  will  a  rheumatic  diathesis  be  established  early, 
but  the  disposition  will  increase  until  it  issues  in  a  paroxysm 
of  acute  rheumatism. 

In  others  who  are  attentive  to  their  general  health,  and 
carefully  avoid  unnecessary  exposure,  the  soil  is  uncongenial, 
and  the  seeds  either  lie  dormant,  or  fail  to  attain  their  perfect 
growth,  for  lack  of  sufficient  nourishment.     The  same  tendency 


50  HEREDITARY    DISPOSITION   TO    RHEUMATISM. 

to  mal-assimilation  may  exist,  but  so  much  caution  is  observed, 
and  such  iininediate  steps  are  taken  on  the  slightest  appear- 
ance of  functional  disturbance,  to  check  or  arrest  the  progress 
of  disease,  that  no  root  can  be  taken  before  that  element, 
which  is  essential  to  the  growth  of  the  seed,  is  eliminated  or 
got  rid  of  from  the  system.  Thus,  although  a  disposition  to 
rheumatism  may  arise,  and  may  be  evinced  by  the  presence  of 
wandering  rheumatic  pains,  yet,  with  due  care,  a  paroxysm  of 
rheumatic  fever  may  be  warded  off,  and  the  tendency  to  the 
disease,  for  a  time  at  least,  got  rid  of.  There  is,  however, 
cause  for  serious  apprehension  when  rheumatic  symptoms  have 
begun  to  manifest  themselves,  inasmuch  as,  however  slight  or 
trivial  in  their  character,  they  are  certain  evidences  of  a  con- 
stitutional change,  which  may  eventually  terminate  in  a  par- 
oxysm of  acute  rheumatism ;  and  the  least  want  of  caution, 
the  least  exposure,  may  induce  an  immediate  and  violent 
attack. 

The  hereditary  disposition  to  rheumatism  has  been  often 
overlooked  or  disregarded.  Its  existence,  however,  to  a 
remarkable  degree,  does  not  admit  of  reasonable  doubt.  I 
have  known  several  families  who,  for  two  generations,  have 
been  grievously  tormented  with  the  disease,  and  in  sundry  of 
whose  members  it  has  repeatedly  appeared  in  its  most  acute 
and  terrible  form.  Circumstances  not  unfrequently  concur  to 
render  our  efforts  to  trace  its  hereditary  character  difficult, 
and  often  to  make  them  unavailing,  yet  we  cannot  but  feel 
surprised  at  the  large  number  of  cases  in  which  its  existence 
can  be  clearly  ascertained.  The  records  of  the  Consumption 
Hospital  exhibit  the  operation  of  an  inherited  predisposition 
in  little  more  than  24  per  cent,  of  the  cases  there  admitted  ;' 
and  the  annals  of  insanity  supply  data  to  prove  that  its  influ- 
ence obtains  in  less  than  13  per  cent,  among  the  inmates  of 
lunatic  asylums  ;^  whereas,  among  the  rheumatic  patients 
admitted    into    St.    George's    Hospital,    I   have    traced   it    in 

1  See  "  First  Medical  Report  of  the  Consumption  Hospital." 
*  For  tables  illustrative  of  this  subject,  see  the  "  First  Medical  Report  of  the 
Consumption  Hospital  at  Brompton." 


HEREDITARY   TENDENCY    TO    RHEUMATISM.  51 

nearly  29  per  cent.  ;^  and  M.  Chorael  distinctly  ascertained  it 
in  half  the  cases  admitted  into  the  Hotel  Dieu.^  Nor  is  this 
the  only  one  evidence  which  can  be  offered  in  its  favor.  M. 
Roche^  has  expressed  his  firm  belief  in  its  hereditary  ten- 
dency ;  and  Dr.  Maclcod/  and  other  physicians  of  eminence 
in  this  country,  have  arrived  at  the  same  conclusion.  More- 
over, this  hereditary  tendency  exists  almost  invariably  in  the 
cases  which  are  earliest  and  most  fully  developed  f  and  we, 
therefore,  cannot  fail  to  join  M.  Chomel  in  exclaiming,  that 
the  just  and  striking  expression  of  Baillon^ — "ut  bonorum 
haereditates,  ita  et  morborum  successiones  ad  posteros  prove- 
niunt" — most  fully  applies  to  rheumatism. 

I  would  not,  however,  be  understood  to  imply  that  rheuma- 
tism is  always  hereditary.  Doubtless  a  rheumatic  diathesis 
may  be  acquired  under  various  circumstances,  and  my  observ- 
ation only  goes  to  the  extent,  that  a  person  who  from  youth 
has  suffered  severely  from  rheumatism,  will  probably  transmit 
a  rheumatic  tendency  to  his  offspring. 

At  what  age,  then,  is  this  diathesis  developed  ?  Or,  to  put 
the  question  in  a  more  practical  form, — At  what  age  does  rheu- 
matism generally  appear  ? 

It  will  be  seen  by  reference  to  Table  II,  appended  to  this 
Chapter,  which  gives  the  result  of  Dr.  Macleod's  and  M. 
Chomel's  experience,  as  well  as  my  own  observations  on  the 
subject,  that  the  usual  age  for  the  development  of  the  acute 
disease,  is  from  about  the  period  of  incipient  puberty,  until  the 
powers  of  the  system  begin,  in  some  measure,  to  fail,  very  few 
cases  occurring  before  the  age  of  15,  and  comparatively  few 
after  the  age  of  50. 


In  St.  George's  Hospital      .     246  71 

Other  Patients  .       84  25 

2  "Lemons  tie  Clinique  Medicale,"  torn,  ii,  p.  126. 

•''  "  Dictionnaire  de  Mudecine  et  de  Cliirurgie  pratiques." 

♦  "  On  Rheumatism,"  p.  3. 

•''  See  Table  I,  appended  to  this  Chapter. 

*  "  Ballonii  Consiliorum  Medicinalium,"  lib.  iii. 


28-8 
29-7 


52  AGE   OF   DEVELOPMENT. 

It  must  not  be  supposed,  however,  that  rheumatism  is  con- 
fined to  the  ages  just  specified.  Our  sensations  teach  us, 
that  we  grow  more  rheumatic  as  we  grow  older ;  and  the  result 
of  extended  medical  observation  shows,  that  the  disease,  though 
not  occurring  in  an  acute  form  in  advanced  life,  does,  never- 
theless, invade  our  stiffening  limbs  more  commonly  than  some 
persons  have  been  inclined  to  admit. ^  The  cause  of  the  differ- 
ence in  the  type  of  the  disorder  at  different  ages,  admits  of 
satisfactory  explanation.  As  rheumatism  is  due  to  the  pres- 
ence of  a  materics  morbi,  generated  during  the  destruction  and 
re-formation  of  the  tissues,  processes  which  take  place  with  unu- 
sual activity  during  early  life,  and  more  slowly  as  age  advances, 
it  follows  that  mal-assimilation  is  more  likely  to  be  attended 
with  an  abundant  formation  of  the  rheumatic  poison,  and  there- 
fore, with  greater  severity  in  the  rheumatic  symptoms,  in  early 
than  in  advanced  life.  Moreover,  it  appears  to  be  a  merciful 
law  of  Providence,  that  as  man's  age  advances,  and  the  system 
becomes  less  able  to  bear  up  against  the  wear  and  tear  of 
severe  illness,  its  natural  susceptibility  to  acute  disorders  should 
be  materially  lessened.  It  thus  becomes  comparatively  insen- 
sible to  the  poison  of  scarlatina  and  marsh  miasmata,  and  to 
the  influence  of  many  other  noxious  matters.  So  also  in  regard 
to  the  effect  of  local  injuries.  The  blow  which,  in  a  young 
man,  would  have  given  rise  to  acute  local  inflammation  and 
symptomatic  fever,  will,  in  the  old  man,  probably  induce  little 
more  than  temporary  pain  and  stiffness,  or  should  inflammation 
be  set  up,  it  will  generally  be  of  a  subacute  character.  Thus, 
the  development  of  the  acute  form  of  rheumatism,  in  advanced 
life,  is  rendered  improbable,  not  only  by  the  source  and  nature 
of  its  materies  morbi,  but  by  reference  to  other  febrile  and 
inflammatory  affections.^ 

A  parity  of  reasoning,  however,  would  lead  us  to  anticipate 

»  See   Tab.  ITI,  p.  58. 

2  The  diminished  susceptibility  to  irritation  exhibited  by  the  system  gen- 
erally, is  displayed  most  strikingly  in  the  fibrous  textures,  the  usual  seat  of 
rheumatic  inflammation.  The  great  Bichat  says,  "  Dans  les  vieillards,  le  sys- 
teme  fibreux  devient  de  plus  en  plus  dense  et  serre." 


CAUSES  WHICH  MODIFY  THE   FORM  OF  THE  DISEASE.         53 

a  more  constant  tendency  to  the  formation  of  the  poison  in 
advanced  years,  and  a  more  frequent  occurrence  of  symptoms 
indicating  its  presence  in  the  system.  And  such  is,  indeed, 
too  frequently  the  case.  So  common  is  some  degree  of  mal- 
assimilation  in  advanced  life,  and  so  constant  the  tendency  to  the 
formation  of  rheumatic  poison,  that  a  greater  or  less  amount 
of  it  is  almost  always  present.  Its  effects  are  evident  on  the 
slightest  exposure,  on  the  slightest  exciting  cause,  for  pain 
ensues,  wandering  from  limb  to  limb,  often  fixing  on  some  one 
in  particular,  and  not  unfrequently  producing  effusion  into  the 
joint,  with  temporary  thickening  of  the  tendons  in  its  imme- 
diate vicinity.  Thus,  months  will  sometimes  pass  away,  point- 
ing with  the  heavy  finger  of  suffering  to  the  poisoned  condition 
of  the  circulation.  In  youth  this  is  very  seldom  the  case.  The 
susceptibility  of  the  system  does  not  long  remain  unmoved  : 
either  the  excretory  organs  are  stimulated  to  thro*'  out  the 
morbific  matter ;  or,  if  not,  the  constant  presence  of  an  irri- 
tant matter,  which  has  accumulated  sufficiently  to  give  rise  to 
pain,  soon  rouses  the  system  to  action,  symptomatic  fever  is 
set  up,  and  ushers  in  an  attack  of  acute  or  subacute  rheu- 
matism. 

Sometimes,  however,  a  person  advanced  in  years  does  suffer 
from  acute  rheumatism,  while,  on  the  other  hand,  a  person  not 
yet  past  his  prime  is  occasionally  tormented  with  the  chronic 
form  of  the  disease.  And  the  phenomena  observed  in  the 
cases  alluded  to,  entirely  confirm  the  view  I  have  taken.  In 
the  former  instances  the  patient  is  invariably  vigorous  for  his 
age,  active,  and  otherwise  of  a  strong  constitution — one,  there- 
fore, whose  system  is  still  susceptible  of  irritation,  and  still 
prone  to  set  up  acute  inflammatory  action ;  while,  in  the 
latter,  the  poison  is  either  generated  in  small  quantity,  as  is 
evidenced  by  the  slightness  of  the  functional  disturbance,  or 
the  patient  is  of  a  sluggish,  inactive  disposition,  and  phleg- 
matic temperament — one,  therefore,  whose  system  is  difficult  to 
rouse  so  as  to  set  up  an  acute  paroxysm  of  the  disease. 

I  maintain,  then,  that  the  liability  to  rheumatism  increases 


54        AGENCIES    INFLUENCING  THE  FORM  OF  THE  DISEASE, 

with  advancing  years ;  that,  in  early  childhood,  it  is  very 
uncommon,  but,  in  adult  life,  one  of  the  commonest  and  most 
troublesome  complaints  which  flesh  is  heir  to;  that  although 
the  chronic  form  of  the  disease  rarely  appears  in  the  irritable 
state  of  the  system  which  occurs  in  youth,  and  the  acute  form 
seldom  arises  when  the  irritability  of  the  constitution  is  blunted 
by  age,  yet  that  the  variety  in  form  depends,  not  on  any  differ- 
ence in  the  proximate  cause  of  the  disease,  nor  on  any  differ- 
ence in  the  character  of  the  materies  morbi,  but  on  the  quan- 
tity of  the  poison  present,  on  the  nature  of  the  constitution  to 
be  acted  on  by  it,  and  on  the  influence  exerted  by  age  and  its 
accompanying  changes  in  the  system.  Such  are  the  agencies 
which  modify  the  form  which  the  disease  assumes,  and  the 
result  of  their  operation  will  be  seen  by  an  inspection  of  Table 
III,  appended  to  this  Chapter.' 

It  has  #)een  asserted,  that  the  occurrence  of  an  acute  attack 
of  the  disease  tends  to  strengthen  the  disposition  to  rheuma- 
tism. But  this  is  certainly  not  the  case,  A  paroxysm  is  evi- 
dently but  an  effort  of  the  constitution,  and  generally  for  the 
time  an  effectual  effort,  to  get  rid  of  the  poison  ;  and  it  is  highly 
improbable  that  such  an  action  should  tend  to  perpetuate  a 
diathesis,  the  effects  of  which  itself  is  set  up  to  counteract.  If 
such  were  the  case,  the  victim  of  a  well-developed  attack  of 
the  disease  would  inevitably  be  a  martyr  to  rheumatism  for  the 
remainder  of  his  life ;  whereas  the  occurrence  of  a  single  acute 
attack  is  by  no  means  uncommon  when  exciting  causes  are 
subsequently  avoided,  and  the  general  health  is  carefully  at- 
tended to.^  Moreover,  it  is  impossible,  on  such  a  supposition, 
to  account  for  the  rare  occurrence  of  rheumatic  symptoms 
shortly  after  the  subsidence  of  a  well-developed  paroxysm,  and 
for  the  long  period  which  usually  intervenes  between  any  two 
acute  attacks ;  while,  on  the  other  hand,  the  fact  that  if  the 
paroxysm  be  irregular  and  ill  developed,  rheumatic  symptoms 

1  See  page  58. 

*"  Enfin  quclques  examples  preuvent,  que  le  Rheutnatisme  peut  ne  se  mon- 
trer  q'une  fois  dans  tout  le  cours  de  la  vie."     (Chomel,  op.  cit.,  p.  124.) 


CLASS    OF    PERSONS    AND    THE    SEX    AFFECTED.  55 

very  commonly  remain  behind,  points  very  decidedly  to  the 
opposite  conclusion. 

But  when  once  a  paroxysm  has  been  fully  established,  there 
is  too  much  reason  to  dread  its  recurrence  at  some  future 
period,  for  it  is  a  certain  sign  of  a  tendency  to  the  formation  of 
the  rheumatic  poison,  of  the  proneness  of  the  system  to  suffer 
from  its  influence,  and  of  its  power  to  set  up  those  actions  which 
constitute  acute  rheumatism.  Moreover,  in  ordinary  cases, 
but  little  care  is  taken,  after  recovery  from  such  an  attack,  to 
guard  against  a  similar  invasion  in  future.  The  disease  is 
looked  upon  as  the  effect  of  cold ;  and,  therefore,  to  use  the 
common  phraseology,  "when  it  is  fairly  cured,"  no  treatment 
is  subsequently  adopted ;  no  means  are  taken  to  improve  the 
general  health  ;  the  patient  having  for  the  time  got  rid  of  the 
materies  morbi,  feels  as  well,  or  even  better  than  he  had  done 
for  weeks  or  months  previously,  and,  ignorant  of  the  real  cause 
of  the  disease,  is  unwilling,  even  should  his  medical  attendant 
recommend  it,  to  subject  himself  to  further  treatment.  Yet 
this  is  just  the  time  when  medical  interference  is  most  effective 
in  correcting  that  unhealthy  state  of  assimilation  on  which  the 
existence  of  rheumatism  depends,  and  which,  if  not  immediately 
arrested,  will  probably  pass  from  bad  to  worse,  until  it  issues 
again  in  a  paroxysm  of  the  disease. 

The  class  of  patients  and  the  sex  most  obnoxious  to  rheuma- 
tism, call  only  for  a  passing  remark,  as  a  slight  consideration 
as  to  the  cause  of  the  disease  will  suffice  to  point  out  its  more 
favorite  victims.  Those  persons  are  naturally  the  chief  suffer- 
ers who,  through  want  and  privations,  irregularity  of  life,  and 
neglect  of  their  general  health,  are  rendered  most  liable  to  that 
state  of  mal-assimilation  whereby  the  materies  morbi  is  pro- 
duced ;  and  who,  again,  from  the  nature  of  their  occupations, 
are  most  exposed  to  atmospheric  vicissitudes,  and  to  other 
exciting  causes  of  the  disease.  Subject  to  such  modifying  in- 
fluences as  these,  all  classes  of  society  and  both  sexes  are 
almost  equally  liable  to  its  invasion  ;  but  if  the  question  be 
viewed  solely  in  reference  to  its  actual  occurrence,  rheumatism 
will  be  found  more  prevalent  in  the  lower  than  in  the  upper 


56  INFLUENCE    OF    CLIMATE    AND    SEASON. 

ranks  of  society ;  and  in  its  acute,  no  less  than  in  its  chronic 
forms,  more  frequent  among  men  than  among  women.' 

Climate  and  season  are  generally  supposed  to  have  a  power- 
ful influence  over  the  production  of  rheumatism.  Except, 
however,  as  predisposing  and  exciting  causes,  it  has  been  shown 
already  that  they  can  exercise  no  such  power ;  and  the  influ- 
ence they  do  exert,  as  proved  by  experience,  is  just  such  as 
might  be  expected  from  the  nature  of  the  case.  If  the  disease 
be  dependent  on  the  presence  of  a  materies  morbi  in  the  blood, 
a  matter  of  which  the  skin  is  the  peculiar  emunctory,  we  should 
hardly  expect  it  to  occur  so  frequently  in  summer,  when  the 
skin  is  acting  freely,  as  at  that  season  of  the  year  when  cu- 
taneous action  is  comparatively  sluggish.  For  the  same  reason 
we  should  expect  it  to  prevail  chiefly  in  cold,  damp,  and  vari- 
able climates,  for  when  moisture  lends  its  aid  to  cold  in  de- 
pressing the  system  generally,  and  thereby  favoring  the 
generation  of  the  poison,  as  also  in  checking  perspiration,  and 
thus  preventing  its  escape  from  the  system,  then  we  should 
consider  all  things  favorable  for  the  development  of  rheumatic 
symptoms.  Now  facts  are  strictly  in  keeping  with  these  deduc- 
tions. It  is  not  in  the  most  inclement  seasons  nor  in  the  coldest 
climates  that  rheumatism  is  most  prevalent,  but  at  those  seasons 

Males.  Females. 

'  Out  of  623  patients  suffering  from  rheumatism  admitted  under 
my  care  at  St.  George's  Hospital,  during  the  seven  years 
ending  July  31sL,  1855,  there  were, 426         197 

Out  of  1014  rheumatic  patients  admitted  into  St.  George's  Hos- 
pital, under  the  care  of  the  physicians,  during  the  four  years 
ending  December  31st,  1848, 666         348 

Out  of  751  rheumatic  patients  who  came  under  the  care  of  Sir 
Gilbert  Blane,  at  St.  Thomas's  Hospital,  ("  Med.-Chir. 
Trans.,"  vol.  vi) •         .         .547         204 

Total  number  of  cases  2388,  of  which  ....   1539      •   749 
Acute  Rheumatism. 
Out  of  289  cases  of  acute  rheumatism  admitted  into  St.  George's 

Hospital  during  the  four  years  ending  December  31st,  1848,     151  138 

Out  of  136  cases  of  acute  rheumatism  recorded  by  Dr.  Latham, 

("Clinical  Medicine,"  p.  143) 75  61 

Total  number  of  cases  425,  of  which     ....     226         199 


STATISTICAL    REPORTS. 


57 


and  in  those  climates  remarkal)le  for  damp  and  variable 
weather.^  The  disease  occurs  less  frequently  in  the  frosty 
month  of  December,  than  in  the  warmer  but  relaxing  "weather 
of  May,^  and  it  is  not  so  prevalent  in  the  cold  climate  of  Nova 
Scotia  and  New  Brunswick  as  at  the  Cape  of  Good  Hope,  the 
land  of  heaths  and  geraniums.^  It  further  appears  from  ob- 
servations made  in  India  by  Mr.  Malcolmson,  that,  in  its  acute 
form  at  least,  the  disease  is  very  rare  within  the  tropics,  and 
as  we  draw  toward  the  poles  the  symptoms  of  acute  rheuma- 
tism are  almost  unknown.* 


Table  I. 


Table  exhibiting  the  strong  hereditary  tendency  which  exists  among  those  cases  of 
Acute  Rheumatism  which  are  earliest  developed.  The  cases  were  all  admitted  into 
St.  George's  Hospital  between  the  1st  of  January,  1845,  and  the  1st  of  May, 
1848. 


Age. 

Total   num- 
ber of  cases. 

Hereditary. 

Not 
Hereditary. 

Uncertain. 

I  have  no  Note 
on  tlie  subject. 

Under  15 

15 

8 

6 

1 

_ 

15  to  20 

58 

22 

31 

3 

2 

20 25 

63 

19 

36 

3 

5 

25 30 

50 

13 

26 

5 

6 

30 35 

22 

.5 

13 

1 

3 

35 40 

17 

3 

8 

2 

4 

40 45 

9 

— 

7 

— 

2 

45 50 

9 

1 

7 

— 

1 

50 55 

1 



1 





55 60 

2 

— 

2 

— 

— 

246 

71 

137 

15 

23 

In  all  the  four  cases  recorded  as  hereditary,  iu  patients  over  the  age  of  35, 
the  disease  had  manifested  itself  several  times  previously ;  in  one,  indeed,  no 
^ess  than  four  times.  Two  of  those  who  were  between  the  ages  of  30  and  35 
had  experienced  two  previous  attacks,  and  two  others  had  ouce  before  under- 

1  See  Table  IV,  appended  to  this  Chapter,  p.  GO.  2  jbjQ 

*  Out  of  luOO  patients  admitted  into  the  Military  Hospitals  in  different  parts 
of  the  world,  there  are  29  rheumatic  patients  in  Jamaica,  30  in  Nova  Scotia  or 
New  Brunswick,  50  in  Great  Britain,  and  57  at  the  Cape  of  Good  Hope,  giving 
a  proportion  of  less  than  three  per  cent,  in  the  two  former  places,  and  of  five 
per  cent,  and  upwards  in  the  two  latter.  The  numbers  are  quoted  in  Craigie's 
"Practice  of  Physic." 

*  Le  Rheumatisme  se  presente  rarement  pres  de  I'equateur  et  des  poles  et 
devient  successivement  plus  commun  a  mesure  qu'on  s'eloigne  de  ces  regions, 
et  regne  surtout  dans  les  Zones  temperees.     (Chomel,  op.  cit.,  p.  4G2.) 


53  STATISTICAL    REPORTS    ON   THE 

gone  a  similar  infliction.     But  even  taking  the  Table  as  it  stands,  it  exhibits 

the  influence  of  an  inherited  predisposition  in — 

1  out  of  every  1-9  patients  under  the  age  of        15 
1         "  2-6       "  "  20 

1         "  3-5       "         between  the  ages  of  20  and  30 

1         "  6-6       "         over  the  age  of  30 

Mons.  Chomel's  experience  coincides  with  this.     He  says,  (op.  cit.,  p.  135,) 

"  II  est  bon  de  remarquer  que  dans  les  cas  ou  I'enfance  est  ainsi  atteinte  contre 

la  r^gle  c'est  presque  toujours  sous  la  triste  influence  de  rhcrcdite." 


Table  II. 

Table  exhibiting  (he  result  of  various   Observations  as  to  the  Age  at  which  Acute 
Rheumatism  most  commonly  occurs. 

Of  73  patients  admitted  into  the  Hospital  de  la  Charite,  at  Paris — 
2  were  first  attacked  before  the  age  of        10 
35  "  between  the  ages  of  15  and  30 

22  "  "  '•  30     "    45 

1  "  •'  "  45     "     50 

1  "  after  the  60th  year. 

(Chomel,  op.  cit.,  p.  134.) 
In  this  Table,  however,  M.  Chomel  has  included  both  gout  and  rheumatism, 
so  that  it  shows  too  high  an  average  in  the  latter  years. 


Of  199  patients  suffering  from  acute  rheumatism — 

8  were  between  the  ages  of  10  and  15 
180  "  "  15    "     40 

10  "  "  40    "     55 

1  exceeded  the  age  of  55. 

(iMacleod  on  "Rheumatism,"  p.  152.) 


Of  239  patients  suffering  from  acute  rheum.atisra,  admitted  into  St.  George's 
Hospital,  during  the  four  years  ending  December  31st,  1848 — 
16  were  between  the  ages  of    5  and  15 
241  "  "  15     "    40 

25  "  "  40     "    50 

7  had  passed  the  age  of  50. 
In  one  instance  only  was  the  patient  under  the  age  of  10.  The  disease,  how- 
ever, does  sometimes  occur  at  a  much  earlier  period  of  life.  I  have  under  my 
care,  at  the  hospital,  a  child  only  8  years  old,  suffering  from  dropsy  and  dis- 
eased heart,  the  result  of  two  attacks  of  rheumatism,  one  of  which  occurred  at 
the  age  of  2  years  and  9  months,  and  the  other  at  the  age  of  6  years  and  4 
months  ;  another  child,  only  twenty  months  old,  was  brought  to  me  last  year 
(1855)  with  several  of  its  joints  red  and  swollen  from  rheumatic  inflammation. 
Dr.  Heberdcn  reports  "  the  rheumatism  has  appeared  as  early  as  in  a  child  of 
4  years  old."  Dr.  Watson  relates,  ("Lectures,"  ed.  1,  vol.  ii,  p.  623,)  "I  have 
frequently  seen  it  in  children,  sometimes  as  early  as  the  third  or  fourth  year ;" 
and  Dr.  Davis  states,  ("  Med. -Chir.  Review,"  for  October,  1817,)  "several  cases 


OCCURRENCE    OF   ACUTE    RHEUMATISM. 


59 


of  acute  rheumatism  were  admitted  in  children  of  3,  4,  5,  6,  and  7  j'cars  of  age 
and  upwards." 


Table  III. 


Table  o/  1014  Cases  of  Eheumatism  and  Rheumatic  Go\U,  admitted  into  St.  GeorgeJs 
Hospital,  during  the  four  years  ending  December  Z\st,  1848,  shelving  the  form  of 
the  disease,  and  the  age  and  sex  of  the  Patients. 


Age. 

Acute 
Rheumatism. 

Subacute 
Rheumatism. 

Chronic  Rheu- 
matism, inclu- 
ding Sciatica 

Rheumatic 

Gout. 

TOTAL. 

5tol0 

Men.     Women. 
1             — 

Men.  Women. 
2          — 

Men.  Women. 

Men.  Women. 

Men. 
3 

Women. 

10—15 

4            11 

4           '3 

4            2 

—             1 

12 

17 

15—20 

22            45 

17          10 

18          12 

3            6 

60 

73 

20—25 

37            35 

26          10 

37          13 

8            4 

108 

62 

25—30 

31            25 

23          12 

67          12 

5            8 

126 

57 

30—35 

15            11 

13            9 

46          10 

9            7 

83 

37 

35—40 

15              5 

10            4 

37          16 

10            8 

72 

33 

40—45 

9              3 

3            4 

33            5 

12          11 

57 

23 

45—50 

11              2 

5            1 

32          12 

14           3 

62 

18 

50—55 

•)            

2         — 

17          7 

6            7 

27 

14 

55—60 

3              1 

2         — 

26           4 

8            3 

39 

8 

60—65 

1            — 

—         — 

4            2 

2            3 

7 

5 

65—70 

—            — 

—         — 

3            1 

5         — 

8 

1 

70—75 

—            — 

—         — 

1          — 



1 



75—80 

—            — 

—         — 

1          — 

—         — 

1 

— 

151          138 

107       53 

326       96 

82        61 

666 

348 

In  this  table,  however,  I  am  satisfied  that  many  cases  are  included  under  the 
title  of  Rheumatic  Gout,  which  ought  to  have  been  classified  under  the  head 
of  Gout,  for  later  and  more  experienced  observation  has  convinced  me  that 
many  cases  of  pure  Gout  occur,  which  an  inexperienced  eye  is  unable  to  dis- 
tinguish from  Rheumatic  Gout,  and  that  true  Rheumatic  Gout  is  of  fiir  less 
frequent  occurrence  in  men  than  the  above  table  would  indicate.  Subjoined 
is  a  table  of  the  last  285  cases  of  Rheumatic  Gout  which  have  come  under  my 
care,  whether  in  hospital  or  private  practice. 


RHEOMATIC    GOUl 

Age. 

Men. 

Women 

Age. 

Men. 

Women. 

Total. 
Men.    Women. 

5tol0 



1 

45  to 50 

5 

24 

10—15 

— 

3 

50—55 

3 

17 

52         332 

15—20 

3 

14 

55—60 



9 

20—25 

5 

27 

60—65 

1 

7 

25—30 

11 

21 

65—70 

— 

2 

30—35 

9 

37 

70—75 

— 

2 

35—40 

7 

31 

75—80 



— 

40—45 

8 

37 

In  men,  the  disease  occurs  most  commonly  in  sequel  of  the  cachexia  in- 
duced by  syphilis  and  gonorrhoea. 


60 


STATISTICAL   REPORTS. 


Table  IV. 

Table  exhibiting  the  Influence  of  Season  upon  the  production  of  Rheumatism. 

Out  of  623  rheumatic  patients,  admitted  as  out-patients,  under  my  care  at 

St.  George's  Hospital,  during  the  seven  years  ending  July  31st,  1855,  there 

occurred — 

In  Januar}',  53  ;  in  February,  54  ;  in  March,  51  ;  in  April,  60    .         .     z=218 
"    May,  57;  in  June,  48;  in  July,  52  ;  in  August,  49  .         .         .     =206 

"    September,  54  ;  in  October,  48  ;  in  November,  50 ;  in  December,  47     =199 
Out  of  1014  rheumatic  patients  admitted  into  St.  George's  Hospital,  under 

the  care  of  the  physicians,  during  the  four  years  ending  December  31st,  1848, 

there  occurred  in — 


Acute. 

Subacute. 

Chronic. 

Elieumatic 
Gout. 

Total. 

January 

27 

13 

44 

14 

98] 

February 

27 

12 

23 

10 

97  1-3*3 

March     . 

28 

18 

36 

15 

April 

23 

15 

27 

11 

76J 

May 

30 

14 

40 

16 

100] 

June 

21 

10 

34 

21 

86   [ooo 

July        . 

14 

10 

27 

14 

65  f 328 

August  . 

16 

11 

41 

9 

77J 

September 

22 

16 

45 

15 

98] 

October 

27 

11 

37 

5 

80     ,40 

November 

28 

19 

29 

10 

86  (-343 

December 

26 

11 

39 

3 

79J 

289 

160 

422 

143 

1014 

CHAPTER  III. 

ON  THE  SEAT  OF  RHEUMATISM. 

Much  difference  of  opinion  has  existed  among  physiologists 
as  to  the  precise  localities  or  textures  of  the  body  which  become 
the  seat  of  pain  and  inflammation  in  rheumatism.  Some 
persons  hare  referred  to  the  muscular  structures  as  the  primary 
seat  of  the  disease,  and  have  maintained  that  other  parts  are 
attacked  in  consequence  of  their  proximity  to  those  first  af- 
fected. Some  have  imagined  the  tendons  ta  be  its  primary 
seat,  and  some  have  confined  its  action  to  the  ligaments ;  while 
others,  taking  a  wider  range,  have  given  it  a  choice  among  all 
the  fibrous  textures  of  the  body.  Some,  again,  unwilling  to 
recognize  its  constitutional  origin,  and  unable  otherwise  to  ex- 
plain the  frequent  shifting  of  its  local  symptoms,  have  suggested 
the  aponeurotic  sheaths  and  the  fascise  as  its  seat,  and  suppos- 
ing its  effects  to  spread  by  continuity  of  surface,  have  thus 
endeavored  to  explain  its  attacks  on  various  parts  of  the  body. 

Now,  lookincr  at  the  diff'erence  in  these  theories,  based  as 
they  mostly  are  upon  actual,  though -not  very  extended,  observ- 
ation, it  might  be  fairly  inferred  that  no  one  texture  is  exclu- 
sively the  scat  of  irritation  in  rheumatism  ;  and  the  history 
which  has  been  given  of  the  nature  of  the  disease,  borne  out 
by  many  of  its  most  striking  phenomena,  completely  estab- 
lishes the  correctness  of  this  inference.  For  if  rheumatic 
inflammation  be  due  to  the  presence  of  an  irritating  matter  in 
the  blood,  it  is  obvious,  as  all  parts  of  the  body  are  supplied 
by  this  blood,  and  are,  therefore,  equally  exposed  to  its  influ- 
ence, that  all  must  be  more  or  less  liable  to  suff"er.  Such  is 
the  law  respecting  the  action  of  poisons  in  general,^  and  such, 

1  '•  It  is  seldom  that  the  action  of  poisons  is  limited  to  one  membrane,  or 
organ,  or  systetu  of  organs  ;  the  greater  number  of  these  noxious  agents  act  on 
two  or  more  organs,  or  systems  of  organs."  (Ur.  Williams  "  On  Morbid  Poi- 
sons," vol.  i,  p.  4.) 


62  OCCASIONAL   COMPLICATIONS    OF   THE    DISEASE. 

in  fact,  is  found  to  be  the  case  in  regard  to  the  rheumatic  poi- 
son. The  joints  and  the  surrounding  structures  are  the  parts 
most  commonly  implicated ;  but  not  unfrequentlj  the  pericar- 
dium and  endocardium,  the  investing  and  lining  membranes  of 
the  heart,  become  the  seat  of  rheumatic  inflammation,  and,  in 
some  rare  cases,  the  heart  itself  does  not  escape  entirely  un- 
scathed.* The  uterus,  the  kidneys,^  and  more  rarely  the  liver, 
sometimes  experience  the  effect  of  its  irritation,  and  the  lungs  are 
not  unfrequently  affected,  as  is  evidenced  by  the  supervention  of 
bronchitis  and  pneumonia.^  In  some  cases  active  pleurisy 
supervenes,  and  more  rarely  inflammation  of  the  sac  of  the 
peritoneum.*  The  eyes  occasionally  suffer,  as  do  also  the 
testes,  the  skin,^  the  muscles,*'  and  the  periosteum  in  various 

'  For  cases  of  rheumatic  inflammation  and  suppuration  of  the  heart,  see 
"  Medical  Gazette,"'Vol.  iii,  p.  118  ;  a  Note  to  Mason  Good's  "  Study  of  Med- 
icine," vol.  ii,  p.  153;  Dr.  Watson's  "  Lectures,"  ed.  1,  vol.  ii,  p.  287;  and 
"  Trans,  of  the  Pathological  Society."  vol.  ii. 

*  For  a  remarkable  case  in  point,  see  Case  in,  Cap.  vii,  of  this  Treatise.  1 
have  also  seen  nine  cases  in  which  the  urine  has  become  albuminous,  for  a 
few  days,  during  the  course  of  acute  rheumatism,  and  two  in  which  I  detected 
blood  globules  by  the  microscope.  The  most  remarkable  case  in  point,  how- 
ever, is  one  which  occurred  in  University  College  Hospital,  under  the  care  of 
Dr.  A.  T.  Thompson,  and  which  has  been  recorded  by  Dr.  John  Tajlor, 
("  Med.-Chir.  Trans.,"  vol.  xxviii.)  "  The  urine  was  not  albuminous  on  the 
patient's  admission,  but  in  a  short  time  it  became  so  highlj'  charged  with  this 
principle  as  to  assume  a  solid  form  on  being  heated,  and  its  specific  gravity  at 
th';  same  time  mounted  to  lOfjO.  After  a  few  days  more  no  trace  of  albumen 
remained,  and  the  urine  had  assumed  its  ordinary  appearance  and  density." 

*  For  cases  in  point,  see  Cap.  X  of  this  work.  Latham's  "  Clinical  Med- 
icine," p.  161.  A  Paper  by  Dr.  Wells,  in  the  "Transactions  of  a  Society,"  &c., 
vol.  iii,  p.  406.  A  Paper  by  Dr.  John  Taylor,  "  Med.-Chir.  Trans.,"  vol.  xxviii, 
pp.  511—13. 

*  For  cases  in  illustration,  see  Case  ii.  Cap.  vii,  of  this  Treati=e ;  as  also 
"  Andral's  Clinique,"  p.  535,  and  "  Med.-Chir.  Trans.,"  vol.  xxviii,  p.  5 12. 

*  Several  remarkable  instances  in  point  have  come  under  my  care  in  St. 
George's  Hospital,  in  which  the  extremities,  upper  as  well  as  lower,  have  been 
covered  with  a  patchy  erythematous  eruption,  resembling  erythema  nodosum. 
The  same  observation  has  been  made  by  others.  Thus  my  colleague.  Dr.  Wil- 
son, says — "During  the  present  summer  of  1844,  two  lads,  aged  15,  fell  under 
my  care  at  St  George's  Hospital,  in  both  of  whom  a  red  patchy  (cutaneous) 
eruption  was  associated  with  the  arthritic  symptoms  of  ill-developed  rheumatic 
fever."  (Dr.  Wilson  on  the  "True  Character  of  Acute  Rheumatism."  "Lan- 
cet," 1844,  vol.  ii,   p.  194.) 

6  See  Notes  of  a  case  in  St  George's  Hospital,  under  the  care  of  Dr.  Bence 
Jones,  reported  in  tlic  •'  British  Medical  Journal,"  Jan.  10,  1857. 


LIABILITY    OF   THE   WHITE    FIBROUS   TISSUE.  63 

parts  of  the  body.  Dr.  Watson  has  reported  rheumatism  of 
the  articulation  of  the  jaw,  Dr.  Cophmd  and  others  of  rheu- 
matic inflammation  of  the  membranes  of  the  spinal  cord,  and 
instances  of  inflammatory  afi"ection  of  the  dura  mater  are  to  be 
found  in  every  work  on  rheumatism.  And  other  parts  are 
secondarily,  even  if  they  be  not  primarily,  implicated,  for  the 
cartilages  of  the  joints  may  inflame  and  ulcerate,'  and  even  the 
osseous  structures  may  become  involved  in  the  mischief.  That 
such  complications  would  occasionally  arise,  might  have  been 
expected,  a  jjrioi'i,  from  the  general  distribution  of  the  cause 
of  irritation,  and  the  severity  of  the  local  symptoms  induced ; 
and,  though  many  of  these  complications  are  happily  of  rare 
occurrence,  and  are  seldom,  if  ever,  met  with  in  otherwise 
strong  and  healthy  subjects,  yet  to  deny  their  existence  is  to 
disregard  facts  which  are  fully  confirmed  by  experience. 

But  not  only  does  the  rheumatic  virus  obey  the  general  law 
of  poisons,  in  that  its  action  is  not  limited  to  any  one  texture 
or  organ  of  the  body,  it  further  resembles  this  class  of  agents 
in  displaying  a  partiality  for  a  particular  texture,  and  partic- 
ular organs  upon  which  it  fixes  in  preference  to  others.  Such 
a  texture  is  the  white  fibrous  tissue,  which  enters  into  the 
formation  of  the  aponeurotic  sheaths,  the  fasciae,  the  capsules 
of  the  joints,  the  ligaments  and  tendons,  and  the  fibrous-serous 
membranes  in  various  parts  of  the  body.  The  parts,  there- 
fore, most  commonly  aff"ected  are  the  joints  and  their  sur- 
rounding structures,  the  valvular  apparatus  of  the  heart,  and 
the  fibrous-serous  covering  of  the  heart,  the  strong  white  glis- 
tening sac  of  the  pericardium." 

1  See  Case  xvi,  Cap   vii,  of  this  Treatise. 

'^  Dr.  Law  observes  that  the  endocardium,  more  especially  that  part  of  it 
which  is  usually  the  seat  of  rheumatic  intlammatiou,  has  its  corresponding 
anatomical  elements  in  the  structure  of  the  joints  ;  the  lining  membrane  of  the 
valves  is  analogous  to  the  synovial  membrane  of  the  joints,  and  the  fibrous 
tissue  which  enters  into  their  composition  to  the  tendinous  structures  which 
enter  into  the  formation  of  the  joints.  So  also  the  pericardium  exhibits,  in  its 
compound  constitution,  its  serous  lamina  corresponding  to  the  synovial  mem- 
brane, and  its  fibrous  lamina  to  the  fibrous  elements  of  the  joints.  To  the 
mitral  valve  having  so  much  more  of  this  fibrous  structure  in  its  composition 
than  the  sigmoid  valves  of  the  aorta,  he  would  ascribe  its  being  so  mu'h  more 
frequently  the  seat  of  rheumatic  inflammation  than  they  are.  (See  "  Dublin 
Med.  Journal,"  vol.  xvi  ) 


64  LIABILITY    OF. PARTICULAR    JOINTS. 

The  reason  of  tliis  predilection  of  the  rheumatic  poison  for 
the  fibrous  and  fibro-serous  textures  throughout  the  body,  is 
not  at  first  sight  obvious,  nor,  indeed,  after  careful  consid- 
eration, can  we  assign  to  it  other  than  a  conjectural  cause. 
But  it  is  Avorthy  of  note,  that  the  textures  most  commonly 
implicated  in  rheumatism  are  all  oiamples  of  the  albuminous 
and  gelatinous  tissues,  from  the  decomposition  of  which,  in  the 
wear  and  tear  of  the  body,  are  formed  those  secondary  organic 
compounds,  the  lithic  and  lactic  acids,  with  which  gout  and 
rheumatism  are  intimately  connected.  And  as  it  is  but  con- 
sistent with  our  knowledge  respecting  the  processes  of  nutri- 
tion and  assimilation,  to  suppose  that  each  tissue  selects  from 
the  blood,  and  appropriates  to  itself  such  matters  as  correspond 
with  it  in  chemical  constitution,  Ave  may  readily  conceive  that 
some  peculiar  attraction  may  be  exerted  by  the  fibrous  and 
fibro-serous  textures  for  compounds,  such  as  the  lithic  and  lac- 
tic acids,  to  Avhich  they  bear  so  strong  an  affinity. 

There  are  some  curious  facts  in  connection  Avith  this  subject 
which  require  particular  notice.  It  has  long  been  observed, 
not  only  that  the  joints  and  the  surrounding  structures  are 
particularly  liable  to  be  affected  by  rheumatism,  but  that  some 
joints  are  more  prone  than  others  to  be  attacked.  Those 
joints,  for  instance,  Avhich  are  most  exposed,  as  the  knees,  the 
feet  and  the  ankles,  the  Avrists  and  the  hands,  are  the  parts 
most  commonly  implicated  :  next  in  order,  perhaps,  folloAv  the 
elbows,  and  then  the  shoulders  and  the  hips.  The  larger 
joints  suffer  more  frequently  than  the  small,  and  the  small 
joints  of  the  hands  and  fingers  more  commonly  than  those  of 
the  feet. 

Those  joints,  again,  which  have  been  the  seat  of  local  mis- 
chief, are  more  than  ordinarily  apt  to  suff'er.  Thus,  a  man 
falls  down  and  sprains  his  ankle  or  his  knee,  and  after  a  time, 
Avith  care  and  attention,  he  entirely  regains  the  use  of  the 
part,  and  experiences  no  inconvenience  from  his  injury.  But 
if  he  is  afterward  attacked  by  rheumatism,  the  joint  which 
had  been  formerly  injured  is  almost  certain  to  be  affected,  and 
Avill  be  so  in  every  subsequent  attack,  and  in  all  probability  it 


SYMMETRY    OF    RHEUMATIC    AFFECTION.  66 

will  be  the  very  part  in  which  the  earliest  local  symptoms  are 
manifested. 

The  same  holds  good  in  regard  to  those  parts  which  are 
chiefly  exercised,  more  especially  when  the  exercise  has  been 
violent  and  long  continued.^  Blacksmiths,  for  instance,  who 
wield  a  heavy  hammer,  very  generally  sufi'er  most  in  the  joints 
of  the  arm  ;  washerwomen  in  the  joints  of  the  hands  and  fin- 
gers ;  gardeners,  and  others  accustomed  to  digging  or  stoop- 
ing, are  exceedingly  liable  to  lumbago  and  sciatica ;  and  post- 
men, and  others  much  employed  in  walking,  are  peculiarly 
subject  to  rheumatism  of  the  legs.  In  all  these  cases  the 
nutrition  of  the  parts  affected  is  unusually  exalted,  their 
power  of  attracting  and  separating  from  the  blood  such  mat- 
ters as  correspond  with  them  in  chemical  constitution  is  pro- 
portionably  increased,  and  hence  the  reason  of  their  being 
aff"ected  prior  and  in  preference  to  other  parts  of  the  body.^ 

Another  fact  to  which  especial  attention  was  first  directed 
by  Dr.  W.  Budd,  of  Biistol,  is,  that,  cceteris  paribus,  corre- 
sponding parts  of  the  body  are  similarly  aflfected.  If  one  knee 
is  attacked,  it  is  probable  that  ere  the  close  of  the  disease, 
more  particularly  if  of  long  duration,  the  other  will  become 
implicated  in  the  mischief  :  if  one  wrist  suifers,  the  other  will 
eventually  sufi'er  also.  Nor  is  it  strange,  if  the  local  afiection 
be  due  to  the  irritative  property  of  any  matter  in  the  blood, 
that  parts  which  correspond  in  function  and  organization,  and 
are  equally  subjected  to  the  same  cause  of  irritation,  should 
suffer  equally  and  in  a  similar  manner.  It  is  only  surprising 
that  any  one  should  hesitate  to  assign  a  constitutional  origin 
to  a  disease  presenting  features  so  strongly  indicative  of  a 
poisoned  condition  of  tlu;  Idood. 

1  Tliis  fact,  I  believe,  was  first  pointed  out  by  Cruveilhier. 

'^  May  not  tliis  be  tlie  true  explanation  of  the  fact,  that  the  pericardium  and 
endocardium  suffer  more  frequently  than  do  the  fibro-scrous  membranes  in 
other  parts  of  the  body?  The  dura  mater,  for  instance,  firm  in  its  attach- 
ments to  an  unyielding  structure,  is  not  exposed  to  any  special  cause  of 
excitation,  whereas  the  heart  is  necessarily  in  a  state  of  great  excitement,  its 
investing  and  lining  membranes  are  consequently  subjected  to  increased  ten- 
sion and  increased  friction,  their  nutrition  is  proportionably  exalted,  and 
everything  therefore  is  in  a  state  to  favor  the  irritative  action  of  the  rheumatic 
poison. 


66  CLASSIFICATION    OF   RHEUMATISM. 

Whatever  the  part  of  the  body  attacked,  the  aspect  of  rheuma- 
tism varies  greatly  in  different  cases.  Sometimes  the  disease  is 
acute  ;  sometimes  mild,  both  in  its  local  and  constitutional 
symptoms;  at  one  time  some  part  of  the  body  is  affected, 
which  at  another,  perhaps,  remains  unaffected  throughout. 
Hence  has  arisen  the  division  of  rheumatism  into  several  dif- 
ferent varieties.  Strictly  speaking,  an}'^  division  must  be  neces- 
sarily incorrect,  inasmuch  as,  however  varying  in  the  locality 
and  intensity  of  their  symptoms,  all  forms  of  the  disease  may 
and  do  constantly  pass  the  one  into  the  other,  and  nothing 
has  been  hitherto  ascertained  as  to  their  pathology  to  justify 
such  a  separation.  But,  doubtless,  pathological  differences  do 
exist,  though  they  have  as  yet  eluded  our  research,  and  prac- 
tically there  is  much  advantage  in  adopting  some  artificial 
arrangement.  Not  only  do  the  different  vai-ieties  occur  under 
different  circumstances  of  age,  sex,  constitution,  and  the  like, 
but  they  require  treatment  differing  widely  in  its  character. 
Hence  it  becomes  expedient  to  make  such  practical  distinctions 
as  are  calculated  from  their  simplicity  to  facilitate  the  descrip- 
tion of  the  various  modifications  of  the  disease  ;  and  those 
which  I  propose  to  adopt  are,  1st,  acute  rheumatism,  or  rheu- 
matic fever  ;^  2d,  rheumatic  gout  ;^  3d,  chronic  rheumatism; 
4th,  neuralgic  rheumatism. 

Acute  rheumatism,  as  its  name  imports,  is  characterized  by 

'  Some  persons  cavil  at  the  term  acute  rheumatism,  and  urge  the  invariable 
adoption  of  the  term  rheumatic  fever,  as  pointing  to  the  constitutional  char- 
acter of  the  disorder.  But  the  fever  which  accompanies  acute  rheumatism  is 
one  only  out  of  many  remarkable  symptoms  which  characterize  a  well-marked 
attack  of  the  disease :  moreover,  the  term  "  fever'  is  more  or  less  applicable  to 
all  the  modifications  of  the  disease,  inasmuch  as  some  functional  dif  turbnnce 
exists  even  in  the  mildest  cases.  Therefore,  unless  the  term  "rheumatic  fever" 
be  applied  indiscriminately  to  all  forms  of  the  complaint,  which  would  lead  to 
endless  confusion,  it  appears  to  me  better  to  adopt  a  nomenclature  which  docs 
not  involve  a  question  of  origin,  rather  than  by  any  title  to  impute  a  functional 
character  to  one  form  of  the  disease  and  by  inference  deny  it  to  another. 

2  By  Dr  Macleod,  these  cases  were  classed  with  true  rheumatism,  under  the 
title  of  synovial  rheumatism  ;  but  I  believe  they  will  be  found  to  have  a  special 
pathology,  and  to  be  totally  distinct  from  rheumatism  and  gout.  I  therefore 
propose  to  consider  them  under  the  common  and  significant  title  of  Rheumatic 
Gout. 


CHARACTERISTICS    OF    ACUTE    RHEUMATISM.  67 

symptoms  of  active  disease.  It  is  generally  ushered  in  by  a 
smart  attack  of  fever,  accompanied  by  a  quick  bounding  pulse, 
a  foul  tongue,  loaded  urine,  profuse,  acid,  sour-smelling  per-  . 
spiration,  and  wandering  pains  in  the  limbs.  After  a  period 
of  varying  duration,  the  pains  fix  on  one  or  more  of  the  larger 
joints,  which  become  hot,  red,  and  swollen,  and  exquisitely 
tender  on  pressure.  Unlike  inflammation  arising  from  truly 
local  causes,  this  rheumatic  inflammation  shifts  repeatedly, 
and  oftentimes  rapidly,  from  joint  to  joint,  displaying  in  each 
great  apparent  intensity,  yet  rarely  producing  permanent  mis- 
chief, so  that  the  joint  which  to-day  seems  to  threaten  suppu- 
ration, may  to-morrow  evince  no  mark  of  the  violent  invasion 
it  has  undergone.  Sometimes  the  swelling  extends  a  consid- 
erable distance  from  the-  joint  itself,  and  is  evidently  chiefly 
external  to  the  articulation,  for  there  is  a  puflSness  about  the 
parts  aff"ected,  and  the  hollows  and  depressions  in  the  vicinity 
of  the  joints  are  filled  up  by  effusion  into  the  cellular  tissue. 
At  others,  the  inflammation  is  less  superficial ;  there  is  less 
redness,  and  the  swelling,  which  is  more  defined  and  limited 
in  extent,  is  evidently  due  in  great  measure  to  inflammation  of 
the  synovial  membrane  with  eff"usion  of  fluid  within  the  joint, 
for  the  distended  capsule  projects  at  those  parts  where  the 
surrounding  tissues  offer  least  resistance.  In  most  instances 
the  two  varieties  of  swelling  are  intimately  blended,  the  diff"use 
fibrous  symptoms  predominating  at  one  period  of  the  disease, 
the  synovial  symptoms  at  another ;  but  in  proportion  as  the 
synovial  symptoms  become  more  prominent,  and  the  diff"use 
fibrous  symptoms  less  marked,  so  does  the  case  assume  more 
and  more  the  character  of  that  form  of  disease  which  I  purpose 
describing  under  the  title  of  Rheumatic  Gout. 

From  first  to  last  the  disease  may  run  its  course  without  the 
implication  of  any  internal  organ  ;  but  not  unfrequently  it  is 
accompanied  by  inflammation  of  the  investing  or  the  lining 
membrane  of  the  heart,  as  also  by  inflammation  of  the  lunge 
or  plourte. 

The  second  variety  presents  some  of  the  characters  of  gout 
more  or  less  blended  with  those  of  rheumatism,  but  is,  never- 


68  DIFFERENT    VARIETIES   OF   RHEUMATISM. 

theless,  essentially  distinct  from  the  ,one  and  the  other.  It 
seldom  occurs  in  early  life,  except  when  there  is  a  taint  of 
gout  or  rheumatism  in  the  system  ;  it  is  not  accompanied  by 
the  profuse  sweating  of  rheumatism,  and  does  not  involve  the 
heart  or  its  membrane.  The  articular  inflammation  is  some- 
times confined  to  one  or  two  joints,  very  generally  affects  the 
smaller  joints,  is  almost  Avholly  within  the  capsule,  or  the 
bursae  or  sheaths  of  tendons  in  its  vicinity,  is  much  less  migra- 
tory than  in  true  rheumatism,  is  marked  by  less  extended  red- 
ness, and  is  accompanied  by  less  active  symptoms  of  fever. 
But  it  is  more  obstinate  in  its  continuance,  more  apt,  when  in 
an  acute  state,  to  induce  disorganization  of  the  joints,  more 
prone,  even  in  a  less  active  form,  to  give  ris^  to  permanent 
thickening  and  enlargement,  and  often  to  frightful  and  irreme- 
diable distortion. 

In  chronic  rheumatism,  the  pain  is  often  referred  to  the  mus- 
cular structures,  and  is  probably  seated  in  the  muscles  them- 
selves, their  tendons,  and  fascioe  :  very  little,  if  any,  redness 
or  swelling  is  produced,  but  the  affected  parts  are  stifl"  and  pain- 
ful, and  the  pain  is  aggravated  by  motion  or  pressure.  Some- 
times, however,  in  cachectic  states  of  the  constitution,  the  pain 
is  referred  to  those  parts  where  the  bones  are  thinly  covered 
by  integument,  as  on  the  shafts  of  the  long  bones,  on  the  ster- 
num, the  clavicle,  and  the  cranium  ;  and  if  the  seat  of  pain  be 
carefully  examined,  there  will  be  found  a  rough  irregular  swell- 
ing, tender  on  pressure,  arising  from  thickening  of,  and  effusion 
under,  the  periosteum  in  that  situation.  Sometimes,  again,  the 
joints  are  more  or  less  affected:  they  are  stiff  and  painful,  and 
present  some  slight  and  temporary  tumefaction,  but  they  are 
not  red,  and  are  seldom  tender  on  pressure,  as  are  the  inflamed 
joints  during  an  acute  attack.  The  local  symptoms  are  migra- 
tory, though  usually  less  so  than  in  the  acute  form  of  the  dis- 
ease ;  there  is  not  much  sweating,  the  urine  is  seldom  loaded, 
and  the  tongue  is  not  greatly  coated ;  in  short,  there  is  far  less 
constitutional  disturbance  than  in  the  acute  form  of  the  disease. 

In  the  fourth  species  the  pain  is  usually  well  defined,  and 


i 


DIFFERENT   VARIETIES    OF   RHEUMATISM.  69 

appears  to  follow  the  course  of  particular  nerves,  more  espe- 
cially those  supplying  the  face  and  the  inferior  extremities. 
The  seat  is  probably  the  sheaths  of  the  nerves,  which  are  either 
simply  irritated  by  the  rheumatic  poison,  or  else  undergo  actual 
inflammation,  accompanied  by  effusion  and  consequent  pressure 
on  the  nerves  themselves. 


CHAPTER  IV. 
ACUTE  RHEUMATISM,  OR  RHEUMATIC  FEVER. 

One  of  the  commonest  and  most  severe  disorders  to  which 
the  inhabitants  of  this  country  are  liable,  is  that  known  as 
acute  rheumatism,  or  rheumatic  fever.  Formidable  as  well 
from  the  intensity  of  the  fever  as  from  the  agonizing  pain  of 
the  limbs  which  it  occasions,  it  is  rendered  peculiarly  fearful 
and  distressing  by  the  consequences  to  which  it  frequently 
gives  rise.  For  the  heart  is  often  damaged  by  the  violence  of 
its  attack,  and  becomes  inapt  for  the  purposes  of  the  circula- 
tion, and  when  this  is  the  case,  the  mischief  gradually  increases, 
until  it  issues  in  palpitation,  dyspnoea,  and  dropsy.  Thus  not 
unfrequently,  in  the  prime  of  life,  the  unhappy  patient  falls  a 
victim  to  a  disease  of  which  the  seeds  were  sown,  perhaps, 
years  before,  during  an  invasion  of  articular  rheumatism. 

Acute  rheumatism  is  usually  met  with  between  the  ages  of 
15  and  50,  few  cases  occurring  before,  and  as  few  after  that 
period  of  life.  It  is  frequently  hereditary,  occurs  in  nearly 
equal  proportion  among  men  and  women,  and  shows  itself 
pretty  uniformly  throughout  the  year.^  At  whatever  age  it 
makes  its  appearance  it  presents  great  diversities  in  its  mode 
of  attack.  It  may  commence  without  previous  notable  derange- 
ment, either  general  or  local  :  the  patient  may  consider  him- 
self in  tolerably  good  health,  when,  on  exposure  to  cold,  or  to 
some  less  obvious  exciting  cause,  he  is  suddenly  seized  with 
aching  pain  and  stiffness  in  the'limbs.  This  gradually  increases 
in  severity,  and  in  the  course  of  a  few  hours,  sometimes  within 
a  shorter  period,  is  accompanied  by  redness  and  swelling,  and 
tenderness  of  the  joints,  as  also  by  symptoms  of  constitutional 
disturbance. 

1  For  statistics  and  full  particulars  on  these  subjects,  see  Cap.  II  of  this 
Treatise,  pp.  56-60. 


ACUTE    RHEUMATISiM.  71 

In  another  case  the  attack  may  be  ushered  in  bj  febrile 
excitement,  marked  bv  all  the  characteristic  features  of  rheu- 
matic fever,  yet  unaccompanied  by  pain  or  the  slightest  artic- 
ular redness  or  swelling,  and  sometimes  the  disease  may  even 
run  its  course  unattended  by  pain  or  local  inflammation.  More 
commonly,  however,  after  a  certain  period,  pain  and  inflamma- 
tion make  their  appearance.  In  most  instances  the  joints  and 
the  surrounding  structures  are  the  parts  which  first  give  evi- 
dence of  irritation,  but  in  some  few  cases,  the  heart  or  its  mem- 
branes are  affected  for  some  time  prior  to  the  setting  up  of 
articular  mischief.^ 

In  another,  and  by  far  the  largest,  class  of  cases,  the  patient 
presents  symptoms  of  functional  derangement  long  before  the 
full  development  of  the  disease.  Though  not  actually  feverish, 
he  is  evidently  "out  of  sorts;"  he  feels  chilly,  languid,  and 
uncomfortable  ;  is  unusually  sensitive  to  atmospheric  vicissi- 
tudes, and  from  time  to  time  experiences  pain,  or  threatening 
of  pain,  in  the  limbs.  His  friends  probably  observe  that  his 
temper  is  irritable,  his  appetite  capricious,  and  that  he  is 
unwilling  to  exert  himself  as  much  as  usual,  and  if  pressed  to 
give  an  opinion  on  the  subject,  they  will  say  he  looks  pale  and 
far  from  Avell.  The  complexion  is  sallow  and  unhealthy,  the 
eyes  are  dull,  and  the  conjunctivae  yellowish.  The  pulse,  per- 
haps, is  hardly  above  the  natural  standard,  but  the  tongue  is 
white  or  coated,  he  has  a  sour  disagreeable  taste  in  the  mouth, 
the  urine  is  high  colored  and  often  turbid,  and  the  bowels  are 
irregular  or  sluggish  in  their  action. 

This  is  the  preliminary  sickening  for  the  attack.  Up  to 
this  point  the  patient  feels  so  little  indisposed  that  he  seldom 
has  recourse  to  medical  advice.  He  fancies  "he  has  caught 
cold,"  and  comforts  himself  with  the  idea  that  "it  will  soon 
pass  off."  But  the  pains  in  the  limbs  become  more  constant 
and  severe  ;  he  finds  it  difficult  to  move,  as  every  attemjit  at 
motion  aggravates  his  suffering ;  and  thus  he  goes  on,  until  he 
is  chilled  by  sitting  in  a  draught,  by  getting  his  feet  wet,  by 
sleeping   in  damp    sheets,  or  by  some  similar  circumstance, 

•  See  Cap.  VI  of  this  Treatise,  Note  on  p.  138. 


72  GENERAL   SYMPTOMS    OF 

when  a  fit  of  shivering  occurs,  unequivocal  febrile  symptoms 
declare  themselves,  articular  inflammation  commences,  and  he 
is  obliged  to  take  to  his  bed.  Then  he  discovers  the  folly  of 
neglecting  the  advice  of  Ovid,  who  says  : 

"  Principiis  obsta ;  sero  medicina  paratur 
Cum  mala  per  longas  invaluere  moras — " 

"VMien  once  a  paroxysm  is  fully  established,  the  patient  pre- 
sents a  pitiable  spectacle  of  helpless  suflfering.  He  is  exceed- 
ingly restless,  yet  lies  motionless  on  his  back,  unable  to  stir, 
afraid  to  allow  himself  to  be  moved  by  his  attendants,  and  in 
constant  dread,  when  they  approach  his  bed,  lest,  by  some 
accidental  pressure,  they  should  aggravate  his  already  agoniz- 
ing pain.  Even  the  weight  of  the  bedclothes  is  too  much  for 
him,  and  he  generally  asks  to  be  relieved  from  their  pressure. 
His  expression  portrays  the  suffering  he  is  enduring,  and  indi- 
cates, at  first  sight,  the  severity  of  the  disease.  Yet  his  aspect 
differs  very  remarkably  from  that  of  a  person  laboring  under 
continued  fever.  It  is  not  so  dull,  heavy,  and  depressed ; 
neither  is  there  the  same  flushing  and  suffusion  of  the  face ; 
nor  the  like  dry  burning  heat  of  skin.  Indeed,  the  counte- 
nance is  seldom  much  depressed,  the  face  is  usually  pale  and 
sallow,  and  though  the  skin  is  sometimes  hot  and  dry,  it  is 
more  commonly  bathed  in  profuse  acid  perspiration,  which 
stands  in  large  drops  upon  the  chest  and  forehead,  and  emits 
a  peculiar,  sour,  disagreeable  odor,  eminently  characteristic  of 
acute  rheumatism.  The  tongue  is  moist,  but  coated  with  a 
deep-white  or  yellowish-white  fur,  and  the  saliva,  which  in 
health  is  alkaline  or  neutral,  becomes  decidedly  acid.  The 
bowels  are  generally  costive,  and  when  acted  on  by  medicine, 
•the  evacuations  are  dark  colored  and  offensive.  The  urine  is 
scanty,  dark  colored,  and  of  high  specific  gravity,  extremely 
acid,  and  loaded  with  lithates,  which  are  deposited  as  a 
copious,  red,  brickdust  sediment.'      The  pulse  is   accelerated, 

'  At  the  outset  of  the  disease,  the  high  specific  gravity  of  the  urine  is  due 
to  a  relative,  rather  than  to  a  positive,  increase  in  the  quantity  of  the  matters 
excreted  by  the  kidneys.  The  solid  constituents  of  the  urine  are  not  in  excess, 
but  the  quantity  of  water  is  far  below  the  average.     In  two  cases  I  have  found 


ACUTE    RHEUMATISM.  73 

varying  in  frequency  from  about  90  to  130  in  a  minute,  and  is 
full  and  bounding  to  a  degree  seldom  observed  in  any  other 
disorder.  The  appetite  varies ;  it  is  generally  impaired,  but 
occasionally  almost  as  good  as  usual ;  and  thirst,  though  some- 
times excessive,  is  not  usually  an  urgent  symptom.  From  first 
to  last,  if  the  case  be  not  complicated  by  some  internal  affec- 
tion, the  head  usually  remains  clear,  the  intellect  unobscured ; 
there  is  no  headache,  no  delirium,  neither  is  there  subsultus 
tendinum,  nor  other  evidence  of  the  disturbance  of  the  nervous 
centers  which  is  commonly  met  with  in  continued  fever.  But 
the  pain  precludes  the  possibility  of  sleep ;  and,  before  the 
disease  has  run  its  course,  the  patient  is  exhausted  and 
becomes  irritable  and  fractious. 

The  local  symptoms  of  the  disease  are  equally  striking  and 
peculiar.  At  first  they  consist  of  little  more  than  pains  wan- 
dering capriciously  from  limb  to  limb,  and  producing  more  or 
less  temporary  stiffness.  But  when  the  attack  is  more  fully 
established,  the  pains,  though  shifting  from  one  spot  to  an- 
other, until  few  parts  of  the  body  have  been  left  free  from  in- 
vasion, fix  more  particularly  upon  the  larger  joints.^  These 
rapidly  pass  into  a  state  of  inflammation,  and  become  hot,  red, 
and  painful,  as  also  tender  to  the  touch.  After  the  lapse  of  a 
few  hours,  effusion  takes  place  into  the  adjacent  cellular  tissue  ; 
the  hollows  and  depressions  about  the  joints  are  obliterated ; 

the  urine  abundant,  pale,  alkaline,  and  turbid,  containing  crystals  of  the 
ammonio-magnesian  phosphate.  In  both  .instances,  the  patients  were  weakly, 
and  their  perspiration  was  of  a  peculiarly  acid  nature.  Something  of  the 
same  sort  has  been  remarked  by  others.  (See  Simon's  "  Chemistry-,"  vol.  ii,  p. 
275.)  Occasionally,  when  there  is  much  renal  irritation,  the  urine  is  slightly 
albuminous,  coagulating  by  heat  and  nitric  acid,  and  a  few  blood  corpuscles 
may  then  be  discovered  in  it  by  the  aid  of  the  microscope  ;  but  usually,  a  few 
scales  of  epithelium,  together  with  an  amorphous  deposit  of  lithates,  and  here 
and  there  a  few  crystals  of  lithic  acid,  or  of  oxalate  of  lime,  are  alone  observed 
on  a  microscopic  examination.  Minute  crystals  of  lithic  acid  are  also  found 
sometimes  in  the  pellicle  which  forms  on  the  surface  of  the  urine. 

^  Other  parts  of  the  body  besides  the  joints  are  liable  to  become  the  seat  of 
pain  in  acute  rheumatism.  Such,  for  instance,  are  the  loins,  the  neck,  the 
scalp,  and  the  parietes  of  the  chest  and  abdomen.  Affection  of  these  parts, 
however,  is  not  so  common  in  the  acute  as  in  the  more  chronic  form  of 
the  complaint ;  and  I  shall  therefore  defer  entering  upon  their  consideration 
until  I  speak  of  Chronic  Rheumatism. 
6 


74  LOCAL   SYMPTOMS    OF 

and  the  surrounding  skin,  which  had  been  hitherto  moist  and 
perspiring,  becomes  dry,  tense,  and  shining ;  so  much  so, 
indeed,  that  experience  alone  enables  us  to  predict  that  sup- 
puration will  not  take  place. 

Sometimes,  however,  the  parts  present  a  somewhat  different 
aspect.  The  articular  swelling  is  more  circumscribed,  and  in 
its  form  and  character  indicates  the  existence  of  effusion  within 
the  joint  rather  than  into  the  surrounding  tissues.  There  is 
less  superficial  redness  and  swelling,  but  there  is  evident  full- 
ness and  distention  of  the  synovial  membrane,  which  bulges  at 
those  parts  where  the  surrounding  tissues  offer  least  resistance, 
forming  a  swelling  in  which  fluctuation  is  perceptible.  These 
two  varieties  of  swelling  are  usually  more  or  less  intimately 
blended,  the  synovial  symptoms  predominating  at  one  period 
of  the  disease,  the  diffuse  fibrous  symptoms  at  another.  But 
in  proportion  as  the  latter  are  absent  and  the  former  are  more 
strongly  marked,  so  does  the  case  lose  the  characteristics  of 
true  rheumatism,  and  assume  those  of  the  disorder  which  I 
purpose  describing  under  the  title  of  Rheumatic  Gout. 

A  remarkable  feature  of  the  articular  inflammation,  is  its 
migratory  nature.  In  the  course  of  a  few  days,  nay,  some- 
times within  a  few  hours,  the  enemy  begins  to  shift  his  quar- 
ters, and  joint  after  joint  undergoes  in  turn  the  infliction  of 
his  terrible  visitation.  The  knee,  which  to-day  is  red  and 
swollen,  may  to-morrow  present  no  trace  of  mischief,  while 
the  wrists,  the  elbows,  the  ankles,  or  the  knuckles,  which  have 
been  hitherto  free  from  pain,  may  in  a  few  hours  become  the 
seat  of  inflammation.  Moreover,  after  evacuating  its  first 
position  and  invading  several  joints  successively,  inflammation 
not  unfrequently  recommences  in  its  old  quarters,  and  the 
parts  go  through  the  same  series  of  changes  to  which  they  had 
been  previously  subjected.  In  some  instances,  however,  the 
parts  first  affected  remain  so  throughout  the  attack ;  and  it 
will  be  observed,  that  the  obstinacy  and  fixity  of  the  inflam- 
mation very  generally  vary  in  an  inverse  proportion  to  the 
number  of  the  joints  implicated. 

The  subsidence  of  inflammatory  action  at  one  part,  and  its 


ACUTE    RHEUMATISM.  75 

commencement  at  another  part  of  the  body,  appear  sometimes 
to  be  simultaneous  actions,  but  more  commonly  the  mutual  de- 
pendence of  these  phenomena  is  by  no  means  clearly  marked. 
A  fresh  joint  may  be,  and  constantly  is,  attacked  without  any 
decrease  in  the  activity  of  the  inflammation  observed  in  the 
parts  primarily  affected,  and  even  when  a  diminution  of  action 
is  perceptible,  it  usually  occurs  slowly  and  imperfectly,  and  the 
parts  first  attacked  remain  for  some  days  tumid,  painful,  and 
tender.  So  that,  in  many  cases  at  least,  the  fresh  inflamma- 
tion set  up  is  obviously  a  mere  extension  of  the  disease. 

Rheumatic  inflammation,  whatever  its  character  and  appar- 
ent intensity,  very  generally  subsides,  without  the  superven- 
tion of  the  ordinary  ill  effects  of  inflammatory  action.^  Some- 
times, indeed,  as  I  shall  presently  point  out,  the  joints  do  go 
on  to  suppuration ;  but  more  commonly  the  redness  and 
swelling  disappear,  the  skin  again  becomes  flaccid,  and  gradu- 
ally resumes  its  perspiratory  function;  and  thus  throughout 
the  whole  course  of  the  disease,  a  series  of  local  changes  is 
kept  up,  which  seldom  leave  any  permament  ill  effects,  though 
varying  greatly  in  the  rapidity  of  their  occurrence,  at  one  time 
occupying  a  few  hours  only,  and  at  another  several  days,  in 
their  completion. 

A  considerable  increase  in  the  severity  of  the  pain  and  some 
exacerbation  of  the  febrile  symptoms,  is  usually  observed  to- 
wards evening,  while,  as  morning  advances,  the  unhappy  pa- 
tient again  experiences  some  remission  of  his  sufferings.  These 
curious  alternations  have  been  attributed  by  some  to  mere  vari- 
ations in  the  external  temperature;  and  the  oft-cited  fact  that 
the  pains  of  rheumatism  are  sometimes  aggravated  by  heat  has 
been  confidently  appealed  to  in  support  of  this  doctrine.^     But 

'  I  here  allude  only  to  the  articular  inflammation,  for  when  the  heart,  the 
lungs,  or  the  pleurae  are  attacked,  the  ordinary  products  of  inflammatory 
action  are  almost  invariably  produced. 

*  That  heat  does  occasionally  aggravate  rheumatic  pains,  is  a  fact  which 
does  not  admit  of  doubt,  but  it  does  so  most  strikingly,  when  it  fails  to  pro- 
duce free  cutaneous  action.  I  have  constantly  observed,  that  those  who  have 
complained  most  of  the  increase  of  pain  induced  by  warmth,  are  loudest  in 
their  praises  of  the  benefit  accruing  from  profuse  acid  perspirations. 


76  PECULIARITIES    OF   ACUTE   RHEUMATISM. 

it  matters  not  at  what  temperature  the  air  of  the  room  be  kept, 
nor  whether  the  heat  be  increased  or  decreased,  as  it  always 
may  be  by  artificial  means,  the  periodical  exacerbation  in  the 
severity  of  the  symptoms  is  still  observed,  and  cannot  be  pre- 
vented; and  the  most  rational  interpretation  of  this  peculiarity, 
which  obtains  even  in  diseases  which  are  benefited  by  warmth, 
is  that  probably  which  ascribes  it  to  some  obscure  influence 
connected  with  the  diurnal  revolution. 

One  of  the  most  remarkable  and  suggestive  facts  in  regard 
to  rheumatism  is,  that  the  fever  and  constitutional  distress  are 
not  necessarily  commensurate  with  the  extent  and  intensity  of 
the  local  symptoms.  Not  only  is  rheumatic  inflammation  of 
the  joints  very  frequently  preceded  by  febrile  disturbance,  but 
sometimes  the  fever  runs  so  high  before  any  local  symptoms 
have  been  established,  as  to  cause  even  careful  and  intelligent 
practitioners  to  mistake  the  nature  of  the  impending  attack. 
Moreover,  when  febrile  symptoms  do  thus  precede  the  estab- 
lishment of  local  inflammation,  they  are  not  only  not  increased 
by  its  occurrence,  but,  as  was  remarked  by  the  sagacious  and 
observant  Sydenham,^  they  are  generally  relieved,  the  pulse 
becoming  calmer,  the  countenance  less  anxious,  and  the  patient 
altogether  easier. 

Another  point  to  be  observed  is,  that  the  pain  is  not  pro- 
portioned to  the  redness  and  swelling,  or,  in  other  words,  to 
the  apparent  intensity  of  the  local  inflammation.  The  pain 
may  be  most  severe,  and,  indeed,  generally  is  so,  just  before 
the  redness  and  swelling  commence,  and,  occasionally,  subsides 
in  some  measure  when  these  external  evidences  of  inflammation 
present  themselves.  Moreover,  it  is  usually  less  severe  when 
much  efi"usion  takes  place  into  the  surrounding  tissues,  giving 
rise  to  a  certain  extent  of  oedema,  than  when  the  parts  are  only 
slightly  swollen,  but  are  exceedingly  hot,  with  the  adjacent 
skin  of  a  dusky,  lurid  red  color.  This  I  believe  to  be  due  to 
the  fact,  that  in  one  set  of  cases  the  superficial  parts  are  chiefly 
affected,  in  the  other  the  ligaments  and  more  deeply-seated 
structures,  which  are  dense  and  unyielding  in  their  nature. 
*  Sydenham,  "  Opera,"  sect,  vi,  cap.  v. 


PERSPIRATION   BENEFICIAL    IN    ACUTE    RHEUMATISM.        77 

The  former  cases  are  accompanied  by  pain  of  a  burning  and 
pricking  character  :  the  latter  by  a  sense  of  gnawing  or  tearing. 
In  the  first-named  instances  the  local  symptoms  are  more  mi- 
gratory, and  shift  their  position  more  rapidly  and  more  com- 
pletely than  in  those  last  mentioned,  in  which,  for  some  days 
after  all  swelling  has  subsided,  there  still  remains  considerable 
stijBTness  about  the  parts,  the  result  probably  of  thickening  in 
the  sheaths  of  tendons,  and  in  the  various  tissues  connected 
with  the  joint. 

The  profuse  perspiration,  characteristic  of  acute  rheumatism, 
is  commonly  spoken  of  as  "wasting  and  enfeebling,"  and  is 
said  to  distress  and  weaken  the  patient  without  alleviating  his 
suffering  or  shortening  its  duration.  This  opinion,  however,  is 
erroneous,  and  a  mistake  of  some  practical  importance.  True, 
the  perspiration  is  often  excessive,  generally  disagreeable, 
sometimes  even  distressing  to  the  patient,  and  fails  in  affording 
immediate  relief.  But  if  it  be  checked  for  a  time,  if  the  outlet 
by  which  such  enormous  acid  secretions  are  making  their  es- 
cape be  closed,  it  will  require  no  very  accurate  observation  to 
mark  the  consequent  increase  in  the  severity  of  the  symptoms. 
The  pains  rapidly  become  worse,  the  constitutional  disturbance 
more  striking  than  before,  and  the  sufferer  himself  will  soon 
observe  that  he  is  easier  and  less  oppressed  when  the  skin  is 
perspiring  than  when  it  is  perfectly  hot  and  dry.  Some  cases 
there  are  which,  for  a  time  at  least,  are  unaccompanied  by  the 
characteristic  sweats,  and  in  these  the  pains  are  always  exces- 
sive, and  the  constitutional  symptoms  most  severe ;  nor  is  any 
relief  obtained  until,  by  the  use  of  proper  means,  the  skin's 
action  is  established  and  perspiration  commences.  The  mate- 
ries  morbi  is  in  great  measure  got  rid  of,  and  the  natural  cure 
of  the  disease  effected  by  means  of  these  profuse,  sour-smelling 
perspirations ;  and  unless  they  be  replaced,  as  they  sometimes 
are,  by  diarrhoia,  diuresis,  or  extremely  acid  vomiting,  every- 
thing which  tends  to  check  them  tends  also  to  protract  the 
disease.  In  the  wards  of  St.  George's  Hospital  I  have  had 
repeated  opportunities  of  noting  this  fact,  and  have  frequently 
begged  the  pupils  to  observe,  that  the  cases  of  rheumatic  fever 


78       PEKSPIRATION    BENEFICIAL    IN    ACUTE    RHEUMATISM. 

which  have  progressed  most  favorably,  which,  though  severe 
in  their  local  and  general  symptoms,  have  run  their  course  in 
a  fortnight  or  three  weeks,  and  have  left  the  patient  free  from 
pain,  have  been  those  accompanied  by  profuse  acid  perspira- 
tions; while  those  which,  in  spite  of  medical  treatment,  have 
lingered  on  for  a  period  of  six  or  eight  weeks,  have  been  those 
in  which  the  sweating  has  been  less  strongly  acid,  less  perfect 
in  its  development,  or  less  constant  in  its  continuance,  taking 
place  over  a  portion  only  of  the  body,  or  occurring  profusely 
perhaps  for  two  or  three  days,  and  then  subsiding  or  altogether 
disappearing.  Indeed,  such  cases  have  usually  continued  until 
the  great  accumulation  of  the  poison  in  the  blood,  with  the 
consequent  increase  in  the  severity  of  the  symptoms,  both 
general  and  local,  have  seemed  once  again  to  stimulate  an  at- 
tempt at  this  system  of  relief.  But  I  would  not  be  misunder- 
stood on  this  subject.  Though  the  characteristic  acid,  sour- 
smelling  perspirations,  which  occur  in  the  natural  course  of 
the  disease,  are  unquestionably  highly  beneficial  to  the  patient, 
as  is  shown  by  the  increased  severity  of  the  symptoms  which 
results  whenever  they  are  forcibly  arrested,  those  certainly  are 
not  so  which  are  met  with  in  debilitated  or  cachectic  states  of 
constitution  ;  which  occur  after  the  incautious  use  of  the  vapor 
bath,  or  depletion  carried  to  an  unwarrantable  extent;  or  which 
again  are  sometimes  witnessed  toward  the  close  of  protracted 
cases.  Such  perspirations  are  useless,  wasting,  and  enfee- 
bling :  though  almost  as  profuse,  they  emit  but  little  of  the 
characteristic  odor;  they  may  be  somewhat  acid,  but  not  highly 
so  as  before ;  they  are  not  attended  by  the  same  heat  of  skin, 
by  the  same  full  and  bounding  pulse,  nor  by  an  equally  loaded 
state  of  urine,  but,  on  the  contrary,  are  accompanied  by  a  sod- 
dened  state  of  skin,  by  a  soft,  weak,  irritable  pulse,  and  not 
unfrequently  by  an  eruption  of  sudamina.  The  former  are 
essential  to  the  safety  of  the  patient ;  the  latter  are,  in  great 
measure,  the  effect  of  debility,  are  enfeebling  and  pernicious  in 
their  continuance,  and  can  and  ought  to  be  arrested.  This 
distinction  may  be  easily  verified  by  careful  observation,  and 
it  is  the  more  important,  because  any  misunderstanding  on  the 


SUBSIDENCE    OF    THE    DISEASE.  79 

subject  might  lead  to  an  erroneous  system  of  treatment;  to  the 
forcible  repression  of  perspiration,  on  the  one  hand,  or  to  its 
inordinate  promotion,  on  the  other. 

When  the  disease  begins  to  subside,  there  is  generally  a 
marked  change  in  the  character  of  the  symptoms ;  the  pain 
becomes  less  constant  and  less  intense,  the  redness  and  swell- 
ing gradually  disappear,  the  frequency  of  the  pulse  subsides, 
the  tongue  begins  to  clean,  the  evacuations  from  the  bowels 
become  less  fetid  and  less  dark  colored,  the  perspiration  less 
profuse  and  less  sour-smelling  than  before,  and  the  urine  more 
abundant  and  less  loaded  with  lithates.  Many  of  these  changes, 
however,  are  not  observed  until  the  disease  is  obviously  on  the 
decline  ;  and,  perhaps,  the  only  means  by  which  it  is  possible 
to  anticipate  a  speedy  subsidence  of  the  symptoms,  is  by 
noticing  the  condition  of  the  tongue  and  urine.  The  former, 
when  the  disease  is  about  to  yield,  begins  to  clean,  and  becomes 
less  red  at  the  tip  and  edges,  while  the  latter  drops  its  sedi- 
ment, becomes  more  abundant,  and  contains  a  larger  quantity 
of  salts,  so  that  it  retains  its  high  specific  gravity,  notwith- 
standing the  increase  in  the  amount  of  water.  Under  the 
microscope,  however,  no  difference  can  be  detected  in  the 
urinary  deposits  at  the  various  stages  of  the  complaint. 

After  a  well-developed  paroxysm  of  the  disease  uncompli- 
cated by  any  internal  affection,  recovery  is  usually  complete, 
and  the  patient  soon  regains  his  former  vigor.  But  in  cases 
in  which  the  symptoms  are  ill  developed,  or  which  occur  in 
strongly  predisposed  persons,  or  in  cachectic  states  of  system, 
a  subacute  or  chronic  form  of  rheumatism  is  apt  to  succeed  the 
more  active  symptoms  of  the  disease.  Either  the  materies 
morbi  is  not  fully  got  rid  of,  or  the  function  of  assimilation 
being  still  imperfect,  fresh  poison  is  generated,  de  novo,  in 
the  system.  Pains  consequently  occur,  which  wander  from 
one  part  to  another,  and  occasionally  are  attended  by  some 
amount  of  articular  swelling.  In  most  instances  these  pains 
gradually  subside,  and  with  them  the  tendency  to  swelling  of 
the  joints ;  but  in  others  they  continue  for  several  weeks,  and 
do  not  ultimately  disappear  until  an  acute  paroxysm  of  the 


80  OPINIONS    RESPECTING    THE 

disease  has  been  re-established,  and  the  poison  through  its 
means  thoroughly  eliminated. 

Sometimes,  after  all  febrile  and  inflammatory  symptoms 
have  passed  away,  there  remains  a  tenderness  and  aching  of 
the  joints  which,  during  the  attack,  have  been  the  seat  of  in- 
flammation. This  must  not  be  mistaken  for  the  subacute  or 
chronic  form  of  the  disease  just  alluded  to,  as  it  is,  doubtless, 
referable  not  to  any  persistent  cause  of  irritation,  but  to  the 
morbid  condition  in  which  the  parts  have  been  left.  The  liga- 
ments, tendons,  fascioe,  and  aponeurotic  sheaths  have  not  re- 
covered their  normal  condition ;  they  are  thickened  and  less 
elastic  than  they  ought  to  be,  and  the  bursse  are  distended  by 
an  unnaturally  thick  fluid,  and  thus  the  parts  are  rendered 
stiff  and  inapt  for  motion.  In  acute  fibrous  rheumatism  this 
is  less  frequently  the  case  than  in  that  form  of  the  disease 
which  sometimes  has  been  called  synovial  rheumatism,  but 
which  I  purpose  describing  under  the  title  of  Rheumatic  Gout. 
When  it  does  occur,  it  may  be  distinguished  from  chronic  rheu- 
matism, by  the  dull  aching  nature  of  the  pain  itself,  by  the 
absence  of  pain  when  the  parts  are  at  rest,  by  the  freedom  from 
pain  in  other  parts  of  the  body,  and  by  there  being  no  evidence 
of  constitutional  derangement. 

The  duration  of  an  ordinary  uncomplicated  attack  of  acute 
rheumatism,  has  been  variously  stated  by  different  writers. 
Dr.  Warren  reported  six  weeks  as  its  ordinary  duration  ;  Sir 
Charles  Scudamore  stated  that  "in  a  case  of  which  the  issue  is 
favorable,  the  fever  and  pains  are  brought  to  a  close  at  the 
end  of  the  third  week,  and  in  slighter  attacks  at  an  earlier 
period ;  but  that  when  the  course  of  the  disease  is  untoward,  a 
period  of  two  months  scarcely  serves  to  exhaust  its  power  of 
producing  even  acute  symptoms."*  M.  Chomel's  experience 
led  him  to  believe  that  four  weeks  is  about  the  average  period 
for  arriving  at  convalescence,  and  that  recovery  never  takes 
place  before  the  twentieth  day ;-  and  Dr.  Macleod  imagined 

'  On  Rheumatism,  p.  2"). 

-  " Le  rheumatisme  articulaire  aigu  quelque  soit  la  medication  employee  ne 
se  termine  jamais  avant  le  vingtieme  jour."  ("  La  Lancette  Franijaise,"  August, 
1834.) 


DURATION  OF  ACUTE  RHEUMATISM.  81 

that,  "with  the  common  methods  of  treatment,  probably  five 
or  six  weeks  may  be  about  its  average  duration."^ 

My  own  observation  has  led  me  to  believe  that,  even  when 
unattended  by  any  internal  affection,  the  disease,  under  ordi- 
nary methods  of  treatment,  endures  very  generally  from  four 
to  five  weeks,  and  under  unfavorable  circumstances  may  be 
indefinitely  protracted.  Of  the  246  cases  admitted  into  St. 
George's  Hospital,  under  the  care  of  the  physicians,  during 
the  time  I  held  the  office  of  medical  registrar,  the  great  major- 
ity were  decidedly  convalescent  about  the  end  of  the  fourth  or 
the  beginning  of  the  fifth  week  from  the  commencement  of  the 
attack,  and  were  ready  to  leave  the  hospital  about  the  end  of 
the  sixth  week.^  And  of  23  other  cases,  part  of  which  I  noted 
in  the  Hotel  Dieu,  at  Paris,  and  part  at  Addenbrooke's  Hos- 
pital, at  Cambridge,  considerably  above  one-half  were  of  about 
the  same  duration.  Experience,  however,  has  taught  me  to 
believe  that  remedial  agents  are  capable  of  still  further  short- 
ening its  duration ;  and  to  such  an  extent  does  this  hold  good, 
that,  as  I  hope  to  show,  the  average  duration  of  an  uncompli- 
cated attack  may  be  reduced,  by  judicious  treatment,  from  a 
month  or  five  weeks,  to  ten  days  or  a  fortnight.  This,  too,  is 
the  conclusion  arrived  at  by  Dr.  Garrod,  who,  since  the  publi- 
cation of  the  first  edition  of  this  work,  in  1852,  has  in  great 
measure  adopted  the  same  principle  of  treatment  as  was  therein 
recommended.^ 

But  the  question  arises  as  to  whether  acute  rheumatism  may 
not  be  immediately  arrested  by  treatment.  Dr.  Macleod  and 
many  other  practitioners  have  maintained,  not  only  that  the 
paroxysm  may  be  shortened,  but  that  it  may  be  cut  short,  if 
treated  vigorously  at  first.  My  evidence,  however,  if  given 
relative  to  the  methods  of  treatment  hitherto  pursued,  must  be 
in  opposition  to  this  pleasant  theory.  While  I  was  following 
the  practice  of  Messrs.  Chomel  and  Rostan,  at  the  Hotel  Dieu, 
at  Paris,  I  paid  great  attention  to  all  the  cases  of  rheumatic 

1  On  Rheumatism,  p.  25. 

2  See  Table,  appended  to  this  Chapter,  p.  84. 

3  See  Med.-Chir.  Trans.,  vol.  xxxviii,  p.  148. 


82  OPINIONS    RESPECTING   THE 

fever ;  I  have  watched  with  equal  care  the  cases  admitted  into 
the  wards  of  St.  George's  Hospital  during  the  greater  part  of 
the  last  ten  years ;  and  in  my  own  practice  at  the  hospital  and 
in  private  life,  have  tested  the  diflferent  modes  of  treatment 
under  which  this  favorable  result  is  said  to  have  been  obtained ; 
but  it  has  not  been  my  lot  to  witness  the  results  ascribed  by 
different  gentlemen,  each  to  his  own  particular  remedies. 
Doubtless,  instances  are  occasionally  met  with  in  which  the 
disease  subsides  rapidly  under  treatment,  but  such  examples 
are  rare,  and  in  my  observation  have  occurred  indiflferently 
under  all  remedies.  The  favorable  result  is  referable  probably 
to  some  change  induced  in  the  functions  of  assimilation,  by 
agencies  altogether  beyond  our  ken,  and  with  ordinary  treat- 
ment it  occurs  so  seldom,  that  it  cannot  be  fairly  cited  as  indi- 
cating the  possession  of  a  power  to  arrest  the  disease. 

With  regard  to  the  great  majority  of  such  cases,  another 
very  simple  and  obvious  explanation  is  applicable,  namely, 
that  the  duration  of  the  disease  is  reckoned  from  the  first  com- 
mencement of  the  treatment,  and  not  from  the  actual  beginning 
of  the  attack.  I  have  seen  several  patients  recover  within  four 
or  five  days  after  admission  into  the  hospital,  but  in  three  cases 
only,  under  the  usual  methods  of  treatment,  have  the  symptoms 
been  thoroughly  subdued  \nthin  fourteen  days  from  the  com- 
mencement of  the  attack.  In  almost  every  instance  of  a  sup- 
posed rapid  cure,  investigation  has  shown  the  attack  to  have 
commenced  some  ten  days  or  a  fortnight  prior  to  the  patient's 
admission  into  the  hospital,  a  sufficient  explanation  of  the  mar- 
velous rapidity  with  which  the  symptoms  have  subsided.  This, 
however,  does  not  hold  good  in  regard  to  cases  treated  after 
the  plan  I  have  recommended ;  for  by  this  method  the  disease 
may  be  generally  arrested  within  a  week,  at  whatever  period 
of  the  attack  the  treatment  may  be  commenced. 

I  have  hitherto  alluded  solely  to  well-developed  and  uncom- 
plicated cases  of  acute  rheumatism,  and  the  remarks  already 
made,  both  as  to  the  symptoms  and  duration  of  the  attack, 
apply  to  such  and  to  such  alone.  The  disease,  however,  is 
often  protracted,  and  rendered  formidable  by  various  compli- 


DURATION    OF    ACUTE    RHEUMATISM.  83 

oations.  One,  which  is  observed  chiefly  when  catarrhal  affec- 
tions are  prevalent,  is  inflammation  of  the  lungs  or  their  in- 
vesting membrane,  excited  no  doubt  by  the  same  cause  of 
irritation  as  gives  rise  to  the  articular  symptoms,  but  arising 
at  one  season  more  than  at  another,  in  consequence  of  the 
poison  being  determined  to  the  lungs  by  the  prevalence  of  an 
epidemic  influence.  Case  after  case  of  acute  rheumatism  has 
been  admitted  into  St.  George's  Hospital  complicated  by  this 
most  alarming  affection,  and  among  136  cases  recorded  by  Dr. 
Latham,  it  was  met  with  in.  no  less  than  24  instances.  More- 
over, in  every  instance  in  which  the  case  issued  unfavorably, 
either  pleurisy,  pneumonia,  or  bronchitis  was  present.^ 

Another,  and  sometimes  a  serious  complication  of  acute 
rheumatism,  is  inflammation  of  the  eye,  generally  of  its  sclerotic 
coat.^  The  proportion  of  patients  in  whom  it  occurs  is  ex- 
tremely small,  and  it  seldom  arises  except  where  there  has 
been  some  cause  of  irritation  to  the  visual  organs,  and  where, 
therefore,  the  poison  of  rheumatism  has  been  specially  de- 
termined to  the  irritated  part.  In  no  instance  have  the  artic- 
ular symptoms  appeared  to  be  relieved  by  its  occurrence,  and 
I  have,  therefore,  been  led  to  regard  it  as  a  mere  extension  of 
the  disease. 

Another  and  most  frightful  complication  of  rheumatism,  is 
inflammation  of  the  brain,  or  its  investing  membranes ;  another 
is  active  maniacal  delirium,  sympathetic  of  inflammation  of  the 
heart  or  lungs,  or  of  the  vitiated  condition  of  the  circulating 
fluid;  and  another  is  suppuration,  or  gradual  disorganization 
of  the  articular  structures.  These  happily  are  also  rare  occur- 
rences. 

The  most  frequent,  the  most  dangerous,  and  in  its  conse- 

1  Latham's  "Clinical  Medicine,"  pp.  1G4-5. 

*  Since  the  publication  of  the  first  edition  of  this  work,  I  have  seen  reason 
to  doubt  whether  inflammation  of  the  eye  is  ever  a  consequence  of  true  rheu- 
matism. Indeed,  the  conviction  has  been  forced  upon  me  that,  when  it  occurs 
during  the  progress  of  articular  inflammation,  which  is  not  of  a  gouty  nature, 
the  coincidence  is  merely  accidental;  or  else  that  the  primary  disease  is 
"gonorrhceal  rheumatism,"  which  is,  doubtless,  referable  to  a  specific  poison, 
and  has  no  connection  with  true  rheumatism. 


84 


COMPLICATIONS   OF   ACUTE   RHEUMATISM. 


quences  the  most  distressing  complication  of  acute  rlieuraatism, 
is  inflammation  of  the  heart  and  its  membranous  envelopes. 
This  merits  the  most  anxious  consideration  of  every  one  inter- 
ested in  the  safety  of  a  rheumatic  patient ;  and  when  discussing 
the  various  complications  of  acute  rheumatism,  I  shall  enter 
fully  into  its  history,  symptoms,  and  treatment. 


Table 

Exhibiting  the  Number  of  Cases  of  Acute  Rheumatism  admitted  into  St.  George's 
Ilospital,  in  each  month  of  the  four  years  ending  December  31,  1848,  and  mark- 
ing the  average  length  of  time  they  remained  in  the  Hospital.  The  great  majority 
of  these  patients  had  been  ill  from  five  to  ten  days  prior  to  their  admission  into 
the  Hosptial. 


January,          

February,   

March, 

Number  of  Patients. 

Average  length  of 
time  in  the  Hospital. 

27 
27 
28 

Days. 
38 
28 
37 

April,          ..... 
May, 

23 
30 

32 
28 

June,           .        .         . 

21 

431 

July, 

August, 

14 
16 

37 
54* 

September, 

October, 

22 
27 

31 
32 

November,       ..... 

28 

33 

December,           .... 
Total, 

26 

28» 

289 

Aver.  35 

1  The  average  of  June  is  rendered  unusually  high  by  the  occurrence  of  1 
case  of  170,  and  1  of  144  days'  duration. 

^  The  average  of  August  is  abnormally  raised  by  the  occurrence  of  four 
cases  of  the  respective  duration  of  70,  84,  99,  and  119  days. 

3  The  average  of  December  is  reduced  by  the  occurrence  of  two  deaths 
within  a  few  days  of  the  patients'  admission,  and  by  the  cure  of  1  patient  in 
11  day.     This  patient  had  been  ill  three  weeks  prior  to  admission. 


CHAPTER  V. 

ON  THE  TREATMENT  OF  ACUTE  RHEUMATISM,  OR 
RHEUMATIC  FEVER. 

If  the  contradictory  nature  of  the  treatment  recommended 
for  the  cure  of  acute  rheumatism  be  taken  as  a  test  of  its  ob- 
stinacy and  intractability,  it  certainly  is  the  most  tedious  and 
intractable  of  diseases.  By  some  "who  have  regarded  it  simply 
in  relation  to  its  inflammatory  character,  it  has  been  considered 
amenable  to  ordinary  antiphlogistic  remedies;  and  bleedings, 
large  bleedings  carried  usque  ad  deliqidujn,  have  been  recom- 
mended by  such  persons  as  essential  to  its  cure.  By  some, 
calomel  alone,  or  calomel  in  combination  with  opium,  together 
with  active  and  repeated  purging,  have  been  used  with  the 
view  of  modifying  its  symptoms;  by  others  opium  has  been 
almost  exclusively  relied  upon  ;  while  many  have  insisted,  with 
equal  warmth,  upon  the  benefit  to  be  derived  from  the  use  of 
guaiacum  and  stimulant  diaphoretics.  Some  have  employed 
cinchona,  some  antimony;  some  have  recommended  alkalies, 
some  acids;  some  have  given  niter  in  large  doses;  others  have 
relied  almost  wholly  upon  colchicum.  Each  remedy  has  had 
its  advocates,  who  have  founded  their  opinion  as  to  its  efficacy 
upon  the  rapidity  with  which,  in  certain  cases,  the  symptoms 
of  the  disease  have  disappeared  after  its  employment.  But, 
as  when  uncomplicated  by  cardiac  affection,  the  disease  usually 
terminates,  sooner  or  later,  in  recovery,  and  sometimes  sub- 
sides with  marvelous  rapidity  under  every  variety  of  remedy, 
it  is  obvious  that  no  sound  inference  can  be  drawn  as  to  the 
success  of  any  particular  method  of  treatment,  unless  such 
treatment  has  been  adopted  largely,  and  has  been  attended 
with  tolerably  uniform  results.  And  I  am  sure  I  may  say, 
without  fear  of  contradiction,  that  each   and  every  plan  of 


86  TREATMENT  OF  ACUTE  RHEUMATISM, 

treatment  which  has  been  hitherto  proposed,  is  regarded  by 
the  profession  as  unsatisfactory.  If  in  one  person's  hands  any 
particular  remedial  course  has  proved  efficient,  it  has  signally 
failed  in  those  of  another ;  if  at  one  time  a  remedy  has  proved 
efficacious,  it  has  been  found  inert  or  injurious  at  another, 
under  different  circumstances  of  age,  sex,  constitution,  and  the 
like.  Nor  does  this  appear  strange  to  those  who  consider  the 
true  nature  of  the  disorder,  and  the  variety  of  circumstances 
under  which  the  physician  may  be  called  upon  to  minister  to 
his  patient's  relief.  The  bleeding,  which  in  the  young,  pleth- 
oric, and  robust,  may  be  necessary  to  allay  excessive  vascular 
action  and  cause  free  secretion,  may,  in  the  weakly,  induce 
irritability  of  the  heart,  and  a  consequent  attack  of  cardiac 
inflammation.  The  opium,  which  in  one  person  may  prove  of 
the  greatest  service  in  promoting  free  perspiration  and  in  allay- 
ing the  general  irritability  of  the  system,  may,  in  another, 
check  the  biliary  and  other  secretions,  and  thus  prevent  the 
elimination  of  the  rheumatic  poison.  The  continued  use  of 
calomel  and  the  constant  purging,  which  may  be  beneficial  to 
one  patient  by  removing  large  quantities  of  unhealthy  secre- 
tions, may  unnecessarily  exhaust  the  strength  of  another,  and 
tend  very  greatly  to  impede  recovery.  And  so  in  regard  to 
every  remedy  which  has  been  proposed.  What  is  useful  at  one 
time,  proves  useless  or  positively  injurious  at  another;  and  the 
conclusion  is  forced  upon  us,  that  what  is  wanted,  "is  far  less 
the  discovery  of  untried  methods  of  treating  disease,  than  of 
discriminative  canons  for  the  proper  use  of  those  we  possess;" 
far  less  the  discovery  of  any  new  medicines,  than  the  adapt- 
ation of  our  present  remedies  to  the  exigencies  of  each  case. 

Unfortunately,  until  within  the  last  few  3'ears,  our  surmises 
respecting  the  origin  of  rheumatism  have  been  confessedly  in- 
correct; our  acquaintance  with  many  of  its  commonest  and 
most  important  phenomena  has  been  imperfect.  Hence  it  has 
been  difficult  to  make  choice  of  proper  remedies,  and  to  appor- 
tion them  rightly  to  the  relief  of  the  disease.  Of  late,  however, 
rapid  progress  has  been  made  toward  a  full  understanding  of 
the  nature  of  the  malady.     Constant  and  diligent  pathological 


OR   RHEUMATIC   FEVER.  87 

research,  by  connecting  many  internal  lesions  witli  its  attack, 
has  gone  far  to  elucidate  the  mystery  of  its  birth;  and  close 
induction,  founded  upon  the  observation  of  its  phenomena 
during  life,  and  upon  the  evidence  of  its  ravages  obtained 
after  death,  has  served  to  jfiU  up  and  illustrate  the  few  uncer- 
tain pages  of  its  history.  So  that,  from  the  knowledge  we 
have  now  acquired,  we  are  justified  in  concluding,  that  its 
symptoms  are  dependent  on  the  presence,  in  the  system,  of  a 
matcries  morbi,  the  product  of  faulty  assimilation — of  vicious 
metamorphic  action;  that  the  articular  inflammation,  though 
very  severe,  subsides,  in  most  instances,  without  leaving  behind 
it  any  trace  of  its  existence,  and  is  peculiarly  prone  to  affect 
any  part  which  has  been  or  is  in  any  way  subjected  to  irrita- 
tion. We  have  learned  that,  although  there  be  excessive  febrile 
disturbance,  it  rarely  leads  to  serious  consequences;  although 
there  be  active  articular  inflammation,  it  does  not  usually  in- 
duce disorganization  of  the  joints;  although  the  disease  be 
accompanied  by  every  symptom  calculated  to  cause  alarm  for 
the  integrity  of  the  structures,  and  for  the  continuance  of  the 
functions  of  life,  it  almost  invariably  terminates  favorably, 
unless  the  heart  or  its  membranes  become  inflamed.  Thus 
have  we  been  taught  to  recognize  and  appreciate  the  grounds 
on  which  our  treatment  should  be  based;  we  have  been  taught 
the  hopelessness  of  attempting  to  subdue  the  fever,  or  allay  the 
pain  and  swelling  of  the  joints,  so  long  as  the  blood  is  infected 
by  the  poison  which  is  at  once  the  source  and  maintenance  of 
the  mischief;  as  also  the  importance  of  neutralizing  the  morbific 
element,  of  promoting  its  elimination,  of  taking  active  means 
to  prevent  its  further  formation,  and  of  avoiding  everything 
likely  to  excite  or  irritate  the  heart,  and  so  to  render  it  prone 
to  inflammation. 

By  what  means,  then,  can  we  best  effect  our  purpose,  and  to 
what  extent  is  it  prudent  to  employ  these  means? 

If  the  matcries  morbi  be  indeed  an  acid,  or  an  acidulous 
compound ;  if  it  be  lactic  acid,  for  instance,  as  there  are  cogent 
reasons  for  believing  it  to  be,  then  will  its  neutralization  be 
effected,  its  irritative  property  probably  diminished,  and  its 


88  TREATMENT  OF  ACUTE  RHEUMATISM, 

elimination  promoted  by  a  free  exhibition  of  alkalies  and  neutral 
salts;  and  these  objects  may  be  further  advanced  by  the  ad- 
ministration of  purgatives,  sudorifics,  and  diuretics,  to  act  upon 
the  various  excretions.  "With  the  view  of  checking  the  further 
formation  of  the  poison,  and  of  restoring  that  healthy  state  of 
assimilation  which,  at  the  outset  of  the  disease,  is  interrupted 
or  arrested,  colchicum,  mercurials,  and  alteratives  may  be 
given,  and,  as  the  febrile  symptoms  begin  to  subside,  may  be 
combined  with,  or  followed  by  the  use  of  quinia,  or  of  some 
other  tonic,  which,  at  certain  stages  of  the  complaint,  may  be 
better  calculated  to  improve  the  function  of  assimilation.  In 
allaying  the  general  irritability  of  the  system,  and  more  par- 
ticularly the  irritability  of  the  heart,  opium,  belladonna,  hyos- 
cyamus,  and  digitalis  are  remedies  of  the  greatest  value;  and, 
if  vascular  action  be  excessive,  and  secretion  sluggish,  blood- 
letting may  be  sometimes  employed  beneficially,  and  antimony 
administered  in  aid  of  other  remedies. 

Such  is  the  rationale  of  the  treatment  to  be  adopted.  When 
the  objects  to  be  accomplished  are  fairly  understood,  the  means 
of  attaining  them  will  be  obvious  to  every  one  conversant  with 
medicine ;  and  the  question  to  be  decided  is  not  so  much  what 
remedies  should  be  employed,  as  in  what  quantities  and  under 
what  circumstances  each  remedy  should  be  made  use  of. 

Before  explaining  my  own  views  on  this  subject,  I  will  take 
a  brief  review  of  the  various  remedies  and  the  chief  methods 
of  treatment  which  have  been  hitherto  recommended  for  the 
cure  of  rheumatism ;  and  first,  as  to  the  heroic  remedy  of  vene- 
section. In  no  disease  is  the  febrile  heat  greater,  the  pulse 
fuller  or  more  bounding,  the  local  inflammation  apparently 
more  severe,  and  accompanied  by  more  pain,  than  in  acute 
rheumatism;  in  none  is  the  blood  drawn  more  buffed  or  cupped ; 
in  none,  therefore,  does  depletioij  promise  greater  success. 
Accordingly,  from  the  time  of  Sydenham,  free  blood-letting 
has  been  had  recourse  to  more  or  less  generally;  by  many  as 
an  auxiliary  to  other  treatment,  by  some  as  a  substitute  for 
all  other  remedies.  Among  the  most  recent  and  strenuous 
advocates  of  large  and  repeated  bleedings,  have  been  Mons. 


i 


OR    RHEUMATIC    FEVER.  89 

Bouillaud  in  France,  and  Dr.  Macleod  in  England.  These 
gentlemen  recommend  the  abstraction  of  three  or  four  pints 
of  IMood  in  the  course  of  the  first  few  days  of  the  attack.* 
They  endeavor  thus  to  lessen  the  force  of  the  heart  and  arteries, 
and  so  to  moderate  local  action ;  and  they  assert,  not  only  that 
they  are  generally  successful,  but  that,  in  many  instances,  they 
have  arrested  or  cut  short  the  disease. 

Now,  without  denying  the  accuracy  of  their  statements,  I 
feel  bound  to  enter  an  earnest  protest  against  the  mode  of 
practice  they  propose.  In  certain  instances  copious  and 
repeated  blood-letting  undoubtedly  appears  to  mitigate,  for  a 
time,  the  severity  of  the  symptoms,  and  to  render  them  more 
amenable  to  other  treatment.  But  if  some  cases  recover  mar- 
velously  under  its  influence,  so  do  they  under  the  use  of  milder 
remedies ;  if,  in  some  instances,  patients  go  on  to  recovery 
without  the  recurrence  of  any  untoward  symptom,  a  far  greater 
number  experience  relapses  in  which  the  disease  returns  afresh, 
with  the  fearful  addition  of  inflammation  of  the  heart;  if  relief 
sometimes  results  from  its  employment,  it  much  more  frequently 
produces  little,  and  but  temporary  abatement  of  suff"ering. 
Nor  are  these  the  only  objections  to  its  employment.  Though 
pain  and  inflammation  may  be  the  most  urgent  and  prominent 
symptoms  of  the  disease,  and  may  seem  to  demand  venesection 
for  their  relief,  still  as  these  symptoms,  if  left  to  themselves, 
subside  almost  invariably  without  leaving  any  ill  effects  behind 
them,  Ave  are  bound  to  hesitate  before  adopting  a  plan  of  treat- 
ment which  cannot  but  affect  the  strength  and  ultimate  well- 
being  of  our  patient.  Even  if  a  predisposition  to  cardiac 
inflammation  be  not  engendered,  as  I  believe  it  to  be,  by  copious 
and  repeated  blood-letting,  still  convalescence  is  retarded,  the 
patient  weakened  and  rendered  liable  to  frequent  relapses.^ 

'  From  three  to  six  pints  of  blood  were  usually  abstracted  by  M.  Bouillaud, 
on  the  first  three  or  four  days  of  the  attack;  and  Dr.  Macleod  was  in  the  habit 
of  taking  "from  twelve  to  twenty  ounces  of  blood  several  successive  times,  in 
the  course  of  five  or  six  days,  from  persons  of  average  robustness."  (On  "  Rheu- 
matism," p.  32.) 

2  This  was  so  remarkably  demonstrated  by  M.  Bouillaud's  cases,  that  the 
doctor  is  forced  to  admit  it  to  be  necessary,  "  d'eviter  avec  le  dernier  soin,  le 
plus  leger  refroidissement."     (Op.  cit.  p.  137.) 


90  TREATMENT    OF   ACUTE   RHEUMATISM, 

"  Unde,"  says  Sydenham,  "non  tantum  gegri  vires  pro  tempore 
franguntur.  sed  si  paulo  fuerit  natura  debilior,  aliis  etiam  morbis 
ad  annos  aliquot  obnoxior  fere  redditur."  Nor  is  this  by  any 
means  a  rare  occurrence ;  many  persons  have  remained  in  a 
weak  and  sickly  condition  for  months,  or  even  years,  after 
having  undergone  Mons.  Bouillaud's  plan  of  treatment  by 
bleedings  repeated  "coup  sur  coup." 

But  what  of  venesection  to  a  smaller  amount  at  the  outset 
of  the  disease  ?  Would  not  a  moderate  bleeding  be  likely  to 
modify  the  local  action,  allay  the  general  irritability  of  the 
system,  and  favor  the  action  of  remedies  ?  I  confess  that, 
according  to  my  experience,  phlebotomy  is  much  too  generally 
adopted.  If  it  could  be  shown,  that  in  the  event  of  its  being 
omitted,  some  serious  mischief  would  arise  as  the  effect  of  the 
articular  inflammation,  that  the  heart  would  be  implicated,  or 
that  some  serious  consequences  would  result  from  the  severity 
of  the  febrile  disturbance,  then  there  would  be  no  objection  to 
the  use  of  the  lancet.  But  the  experience  of  all  ages  has  proved 
beyond  dispute,  that  the  febrile  paroxysm  is  usually  unaccom- 
panied by  danger ;  that  disorganization  of  the  joints  very  rarely 
occurs,  and  supervenes  as  often  when  bleeding  has  been  prac- 
ticed as  when  no  blood  has  been  taken  from  the  arm ;  and  recent 
observation  adduces  evidence  to  show  that  inflammation  of  the 
heart  is  not  more  common,  if,  indeed,  it  be  not  actually  less 
frequent,  where  other  remedies  are  employed,  than  Avhen  a 
treatment  is  adopted  in  which  phlebotomy  has  its  share.  Mons. 
Bouillaud,  the  great  advocate  of  copious  and  repeated  venesec- 
tion, acknowledges  inflammation  of  the  heart  to  have  been  the 
rule,  and  not  the  exception  in  his  practice  :  "  Coincidence  a 
peu  prcs  constante,  soit  d'une  endocardite,  soit  d'une  pcricar- 
dite,  soit  d'une  endo-pericardite  avec  un  violent  rheumatisme 
aigu."  ^  And  Dr.  Macleod,  who  makes  no  mention  of  the  fre- 
quency of  endocarditis,  reports  pericarditis  alone  in  nearly  one- 
fourth  of  his  cases.  On  the  other  hand,  Dr.  Corrigan,  who 
rarely  had  recourse  to  blood-letting,  observed  only  one  instance 
of  it  among  many  cases  treated  by  opium ;  and  out  of  one  hun- 

'  Op.  cit.  Preface,  p.  ii. 


OR    RHEUMATIC    FEVER.  91 

dred  and  sixty-eight  cases  in  my  own  practice,  it  has  occurred 
but  five  times  after  the  commencement  of  treatment,  and  in 
four,  if  not  in  all  of  these  instances,  within  the  first  twenty-four 
hours  before  the  effect  of  treatment  coukl  be  felt.  Nay,  more, 
though  1  have  treated  eighty-three  cases  of  acute  rheumatism 
during  the  last  three  years  and  a  half,  inflammation  of  the 
pericardium  has  not  been  set  up  in  any  one  instance  while  the 
patients  have  been  under  my  care,  a  result  which  I  attribute 
to  the  greater  rapidity  with  which  I  have  lately  pushed  the 
remedies. 

As,  therefore,  there  is  no  absolute  necessity  for  the  use  of 
venesection,  as  it  usually  aff'ords  only  temporary  relief,  and 
as  by  the  treatment  hereafter  to  be  mentioned,  the  pulse  may 
be  quieted,  the  pain  allayed,  and  the  fever  and  articular 
inflammation  subdued  much  more  rapidly  and  certainly  than 
by  the  most  active  depletion,  I  would  not  recommend  the 
abstraction  of  blood  as  a  part  of  ordinary  practice.  In  some 
instances  it  is  required,  and  is  highly  beneficial ;  but  repeated 
observation  has  led  me  to  believe,  that  it  is  so  only  in  first 
attacks  occurring  in  young,  robust,  and  generally  healthy  per- 
sons, particularly  in  those  which  are  marked  by  unusual  severity 
of  their  symptoms,  or  are  unaccompanied  by  free  perspiration, 
and  by  other  evidences  of  activity  in  the  excretions.  Even  in 
such  cases  it  should  be  cautiously  employed,  and  carried  to  a 
small  extent  only,  viz.,  from  six  to  twelve  ounces,  according  to 
the  age  and  strength  of  the  patient,  the  object  being  to  favor 
the  action  of  other  remedies,  and  promote  free  secretion,  rather 
than  to  arrest  or  cut  short  the  disease.*  In  the  recurrent  dis- 
ease, venesection,  even  to  a  moderate  amount,  is  always  unat- 
tended by  benefit,  and  is  sometimes  followed  by  dangerous 

1  I  am  glad  to  quote,  in  confirmation  of  my  opinion,  the  testimony  of  that 
able  and  experienced  physician,  Dr.  Latham.  After  discussing  the  expediency 
of  having  tecourse  to  it,  he  adds :  "  Summarily,  then,  I  would  venture  to  say 
of  venesection,  employed  under  the  most  favorable  conditions,  and  in  the  most 
suitable  measure,  that  it  is  to  be  trusted,  rather  as  preparatory  and  auxiliary 
to  other  remedies,  than  for  its  own  exclusive  remedial  power  in  acute  rheuma- 
tism. It  very  often  renders  the  disease  more  curable  by  other  means,  but  it 
seldom  cures  the  disease  itself."     ("Clinical  Medicine,"  vol.  i,  p.  190.) 


92  TREATMENT  OF  ACUTE  RHEUMATISM, 

consequences ;  in  mild  cases  it  is  unnecessary,  and  therefore  to 
be  avoided ;  in  the  delicate  or  those  of  a  weakly  constitution, 
it  is  clearly  inadmissible ;  and  in  the  strongly  predisposed,  or 
when  the  disease  is  hereditary,  it  utterly  fsxils  in  modifying  the 
morbid  action,  is  often  ill  borne  by  the  system,  and  therefore 
should  seldom  be  practiced.^ 

When  venesection  is  employed  in  acute  rheumatism,  the  blood 

1  In  confirmation  of  my  opinion  as  to  the  general  inexpediency  of  bleeding, 
I  am  induced  to  quote  the  following  practical  observations  :  "  As  far  as  I  have 
been  able  to  observe,  the  benefit  of  large  and  repeated  bleedings  is  in  most 
cases  far  from  clear  and  unquestionable.  One  of  the  worst  rheumatisms  which 
I  remember,  immediately  succeeded  a  most  profuse  bleeding  of  the  nose,  which 
continued  so  long  as  almost  to  exhaust  the  patient,  and  to  bring  his  life  into 
imminent  danger.  Something  like  this  happened  in  a  second  instance."  (Dr. 
Heberden's  "  Commentaries,"  p.  401.) 

"  Some  practitioners  continue  to  let  blood  in  most  cases  of  rheumatism, 
thinking  themselves  justified  in  their  mode  of  practice  by  the  sizy  appearance 
of  the  blood.  The  same  principle  might  lead  them  to  empty  the  whole  san- 
guiferous system,  for  every  time  blood-letting  is  repeated,  the  blood  becomes 
more  and  more  dense  and  sizy.  I  have  further  observed,  that  by  bleeding  re- 
:peatedly,  the  pains,  swellings,  and  febrile  symptoms  are  not  orUij  aggravated  at 
the  time,  but  often  protracted  indefinitely ;  at  least,  I  have  seen  them  continue 
■under  such  a  mode  of  practice  upwards  of  two  months."  (Dr.  'Willan's  "  Re- 
port on  the  Diseases  of  London,"  p.  l"iG.) 

"While  it  was  the  practice  to  remove  the  general  inflammation  by  bleeding, 
metastasis  frequently  took  place  to  the  interior  parts  of  the  body,  and  destroyed 
the  patient.  This  accident  in  the  author's  practice  during  the  last  fifteen  years, 
has  rarely  happened.  In  this  period,  he  has  entirelj-  loft  off  l)leeding  in  acute 
rheumatism,  and  has  not  lost  above  two  or  three  patients,  although  he  has 
treated  several  hundred  in  this  disease."  (Third  Dissertation  on  "  Fever,"  p. 
18,  by  Dr.  Fordyce,  formerly  Physician  to  St.  Thomas's  Hospital.) 

Dr.  Alison  "  has  no  difficulty  iu  stating  his  conviction,  that  large  and  re- 
peated bleedings,  in  the  beginning  of  rheumatism,  increase  the  risk  of  metastasis 
to  the  heart,"  and  "  that  acute  rheumatism  cannot  probably  be  much  shortened 
in  its  duration  by  antiphlogistic  remedies."  (''  Cyclopjfdia  of  -Medicine,"  article 
*•  History  of  Medicine,"  p.  !».">.) 

♦'  Excessive  bleeding,  which  has  been  another  error  in  the  treatment  of  acute 
irheumatism,  may  likewise  protract  the  disorder."  (Dr.  Francis  Hawkins's 
"Gulstonian  Lectures.") 

"  It  rarely  happens,  however,  from  the  age  of  the  patient,  or  the  extreme 
severity  of  the  disease,  that  venesection  is  to  be  had  recourse  to  more  than 
■once."     (Dr.  Seymour's  ""Lectures,"  "  Med.-Chir.  Review,"  vol.  xxxiii.) 

"  On  the  whole,  I  would  conclude  that  large  and  repeated  bleedings  should 
■be  avoided  in  rheumatic  fever."     (Dr.  Todd,  on  "Rheumatism,"  p.  208.) 

"Although  I  am  in  the  almost  daily  habit  of  treating  this  disease,  I  rarely 
prescribe  phlebotomy."     (Dr.  Watson's  •'  Lectures,"  ed.  1,  vol.  ii,  p.  025.) 


OR    RHEUMATIC    FEVER. 


93 


drawn  is  remarkably  buffed  and  cupped,  and  the  patient  will 
bear  to  lose  a  large  quantity  Avithout  fainting.  But  neither  of 
these  facts  is  sufficient  to  justify  the  adoption  of  the  remedy, 
or  to  warrant  its  repetition.  The  tolerance  of  blood-letting  is 
attributable,  without  doubt,  to  the  irritant  property  of  the 
rheumatic  poison,  and  to  the  stimulating  influence  which  the 
blood  acquires  in  consequence ;  and  the  quantity  of  fibrin  in 
the  blood  is  so  increased,^  that  the  cupping  and  buffing  will 
continue  to  the  last — will  continue  when  depletion  is  no  longer 
safe,  and  when  it  has  been  carried  to  such  an  extent  that  an 
anaemic  murmur  accompanies  the  heart's  sounds,  and  a  loud 
bruit  de  diahle  is  audible  in  the  large  veins  of  the  neck. 

In  conclusion,  then,  without  denying  the  occasional  efficacy 
of  venesection  in  acute  rheumatism,  I  seldom,  very  seldom, 
have  recourse  to  its  employment.  Rarely,  indeed,  does  a  case 
occur  in  which  other  and  gentler  means  will  not  reduce  the 
force  and  frequency  of  the  circulation,  promote  free  secretion, 
and  allay  the  fever  and  local  inflammation  as  rapidly  as  the 
most  copious  blood-letting ;  and  whether  owing  to  peculiar 
bodily  idiosyncrasies,  or  to  other  causes  equally  beyond  our 
ken,  the  favorable  results  of  venesection  are  so  rarely  met 

1  Messrs.  Andral  and  Gavarret  have  clearlj-  shown  that  the  increase  in  the 
proportion  of  fibrin  which  rises  in  acute  rheumatism,  from  2J  or  3  to  8  or  9, 
or  even  10-3  parts  in  1,000,  is  due  to  the  existence  of  local  inflammation,  and 
that  bleeding  exercises  very  little  influence  over  it,  unless  it  be  accompanied 
by  a  remission  of  the  local  mischief. 

It  exerts,  however,  a  very  manifest  and  constant  influence  over  the  quantity 
of  blood  corpuscles,  which  diminish  in  proportion  to  tlie  frequency  of  the 
blood-letting,  and  the  amount  of  blood  taken.  In  illustration  of  these  facts,  I 
subjoin  the  result  of  four  bleedings  in  three  cases  of  acute  rheumatism. 


(  Case  i. 

Bleeding  i. 

Bleeding  ii. 

Bleeding  iii. 

Bleeding  iv. 

G-5 

G-2 

7-0 

6-9 

Fibrin    .    . 

"    ii. 

5-4 

7-0 

6-1 

5-4* 

(    "  iii. 

G-1 

7-2 

7-8 

10-2 

r  Case  i. 

114-8 

111-0 

102-8 

88-7 

Globules    . 

"    ii. 

125-3 

124-0 

121-4 

99-6 

1    "iii. 

123-1 

120-7 

112.8 

101-0 

*  In  case  ii,  the  pain  and  inflammation  were  subsiding  at  the  time  of  the 
fourth  bleeding.     ("Annals  de  Chimie,"  vol.  Ixxv,  pp.  240-48.) 


94  TREATMENT  OF  ACUTE  RHEUMATISM. 

with,  and  the  risk  of  evil  consequences  incurred  by  its  employ- 
ment is  so  great,  that,  provided  as  we  are  with  remedies  of 
equal,  if  not  of  greater,  efficacy,  we  are  not  justified,  except 
under  the  conditions  already  specified,  in  having  recourse  to  so 
dangerous  an  expedient. 

In  general  estimation,  perhaps  purging  stands  next  in 
importance  to  venesection.  The  practice  of  giving  large  and 
repeated  doses  of  calomel  and  purgatives  was  first,  I  believe, 
introduced  by  Dr.  Chambers,  and  is  certainly  most  powerful 
in  mitigating  the  severity  of  the  disease.  It  allays  the  pain, 
subdues  the  fever,  and,  day  by  day,  gives  abundant  tokens 
of  its  salutary  influence.  Nor  can  this  be  a  matter  of  aston- 
ishment to  those  who  are  familiar  with  the  features  of  the  com- 
plaint. The  bowels  are  often  loaded  with  unhealthy,  dark- 
colored,  offensive  secretions :  and  by  the  practice  alluded  to, 
not  only  are  these  poisonous  accumulations  got  rid  of,  but  the 
stomach  and  intestines  throughout  their  whole  extent  are  stim- 
ulated to  inordinate  action  ;  the  amount  of  fluid  excreted  is 
vastly  increased,  and  with  it  a  large  quantity  of  the  rheumatic 
virus  must  necessarily  be  evacuated. 

But  if  the  advocates  of  this  system  of  treatment  have  not 
enlarged  too  much  upon  its  value,  they  have  at  least  insisted 
too  strongly  upon  its  invariable  employment.  The  bowels, 
says  Dr.  Macleod,  should  be  acted  on  by  "  calomel  in  doses  of 
from  three  to  five  grains,  administered  at  night,  and  followed 
by  senna  and  salts  in  the  morning.  This  discipline  ought 
generally  to  be  repeated  on  several  successive  days.''^  And 
Dr.  Hope,  in  the  same  strain,  recommends  "  calomel  and  opium 
at  night,  and  a  black  dose  every  morning,  sufficient  to  insure 
four  or  five  stools  at  least."  Now  although,  as  above  stated, 
I  admit  the  necessity  of  attending  to  the  state  of  the  alvine 
secretions,  and  recognize  free  and  copious  evacuations  by  the 
bowels  as  among  the  most  powerful  means  we  possess  of  allay- 
ing the  general  febrile  disturbance,  and  of  promoting  the  elim- 
ination of  the  rheumatic  virus,  I  must,  nevertheless,  express 
my  dissent  from  the  practice  of  repeated  active  purging.     And 

1  On  "Rheumatism,"  p.  34. 


OR    RHEUMATIC    FEVER.  95 

I  do  SO  for  three  reasons.  First,  because  it  is  not  necessary 
to  the  cure  of  the  patient,  and,  like  bleeding,  tends  greatly  to 
reduce  his  strength  and  protract  recovery ;  secondly,  because, 
from  the  nature  of  the  complaint,  the  patient  is  quite  incapable 
of  moving,  and  his  sufferings  are  aggravated,  his  irritability  is 
increased,  and  his  heart's  action  accelerated,  by  the  repeated 
shifting  of  position,  -which  is  rendered  necessary  by  the  calls 
of  nature ;  and,  thirdly,  because  it  necessarily  gives  rise  to 
more  or  less  exposure,  which  must  be  prejudicial  to  a  patient 
bathed  in  perspiration.  On  several  occasions  within  my  own 
experience,  inflammation  of  the  heart  has  supervened  imme- 
diately after  the  exposure,  and  the  increase  of  irritability  con- 
sequent on  several  successive  purgings,  and  more  than  once  I 
have  been  led  to  believe  that  this  unfortunate  occurrence  has 
resulted  from  the  treatment  adopted.  Accordingly,  our  con- 
stant endeavor  should  be  to  obtain  a  free  evacuation  every 
morning,  without  the  risk  and  great  discomfort  attendant  upon 
repeated  purging.  The  remedies  by  which  this  object  is  best 
obtained  are — calomel  combined  with  a  full  dose  of  opium  at 
night,  and  followed,  when  necessary,  on  the  following  morning, 
by  a  draught  composed  of  rhubarb  or  senna  with  colchicum, 
and  the  potassio-tartrate  of  soda,  in  just  sufficient  quantity  to 
produce  one  full  dejection.  By  these  means,  not  only  is  an 
abundant  secretion  secured  from  the  liver  and  bowels,^  but  by 
waiting  some  hours  before  administering  the  purgative,  and 
thus  giving  the  calomel  time  to  do  its  work,  we  carry  off  the 
excrementitious  matter  quite  as  thoroughly  as  by  repeated 
active  purging. 

There  are  certain  cases,  however,  in  which  larger  and  more 
frequent  demands  may  be  made  upon  the  intestinal  secretions. 
It  happens  not  unfrequently  that  persons  attacked  with  acute 
rheumatism  have  been  constipated  for  some  time  prior  to  their 
illness.     Such  persons  present  all  the  symptoms  of  biliary  and 

1  "  The  prompt  and  almost  specific  effect  of  mercury  on  the  liver  cannot  be 
doubted,  but  scarcely  less  in  amount  or  importance  is  its  effect  upon  tlic 
mucous  membrane  and  glandular  follicles  of  the  intestines,  the  secretions  from 
which  are  often  mistaken  for  those  of  the  liver."  (Holland's  "  Med.  Notes  and 
Reflections  ;"  cap.  on  "  Mercurial  Medicines.") 


9G  TREATMENT  OF  ACUTE  RHEUMATISM, 

intestinal  derangement  in  a  very  marked  degree.  They  com- 
plain of  a  sour  and  disagreeable  taste  in  the  mouth,  and  of 
fullness  and  distention  at  the  epigastrium  ;  their  conjunctivae 
are  yellowish,  their  breath  is  often  foul,  the  tongue  inclined  to 
be  dry  and  very  furred  and  yellow,  the  motions  dark  colored 
and  offensive,  the  appetite  altogether  lost.  In  these  cases 
there  appears  to  be  so  much  torpidity  of  the  primse  viae,  such 
an  absence  of  healthy  intestinal  secretion,  and  withal,  prob- 
ably, so  large  an  accumulation,  in  the  s^'stem,  of  matter  Avhich 
ought  to  have  been  excreted  by  the  bowels,  that  it  is  expedient 
to  exact  at  least  two  full  alvine  evacuations  for  the  first  three 
or  four  days  of  the  attack.  And  they  are  generally  accom- 
panied by  signal  relief.  The  aperients,  though  administered 
in  full  doses,  produce  no  griping,  no  tenesmus,  no  appreciable 
distress ;  on  the  contrary,  they  are  folloAved  by  copious,  dark- 
colored,  offensive  dejections,  the  getting  rid  of  which  is  evi- 
dently conducive  to  the  comfort  and  well-being  of  the  patient. 
He  expresses  himself  sensible  of  immediate  relief,  and  the  cor- 
rectness of  his  sensations  is  attested  by  the  greater  moisture 
of  the  tongue,  the  absence  of  the  previously  existing  fetor  of 
his  breath,  and  the  marked  improvement  of  the  general 
symptoms. 

Thus,  then,  while  I  admit  the  necessity  of  close  attention  to 
the  alvine  secretions,  and,  in  some  instances,  would  insist  upon 
repeated  calls  upon  their  activity,  I  feel  persuaded  that  active 
purging  is  sometimes  not  only  unnecessary,  but  extremely 
prejudicial  to  the  safety  of  the  patient.  In  cases  unaccom- 
panied by  those  indications  of  intestinal  derangement  before 
alluded  to ;  in  cases  in  which  the  bowels  are  acting  freely,  and 
the  dejections  are  healthy  and  bilious  in  appearance,  pui'ging 
may  be  useful  as  a  powerful  means  of  draAving  off  the  poison, 
but  it  certainly  is  unnecessary  for  the  cure  of  the  disease,^ 
and  must  not  be  expected  to  afford  the  relief  observed  to  follow 

1  It  is  doubtless  of  these  cases  that  Dr.  Corrigan  speaks,  when  he  gives  it 
as  his  opinion,  that  '■  the  patient's  bowels,  if  they  have  not  been  constipated 
at  the  commencement  of  the  attack,  may  be  not  only  safely,  but  with  beuefit, 
not  disturbed  more  than  once  in  two  days."  ("  Dublin  Med.  Journal,"  vol. 
xvi,  p.  266.) 


OR    RHEUMATIC    FEVER.  97 

its  action  in  those  cases  which  especially  call  for  its  employ- 
ment. Indeed,  as  already  stated,  observation  would  lead  to 
its  being  reserved  for  exceptional  cases.  If  there  be  much 
intestinal  derangement,  a  cure  can  hardly  be  effected  without 
it ;  but  if  there  be  not,  the  discomfort  and  the  risk  attendant 
upon  its  use  are  such  as  to  induce  us  to  look  for  some  other 
means  of  carrying  off  the  rheumatic  poison.  And  as,  "in  a 
combination  hereafter  to  be  mentioned,  an  agent  exists  both 
powerful  and  efficient,  for  the  accomplishment  of  this  object, 
it  is  seldom  necessary  to  exact  an  evacuation  from  the  bowels 
above  once  in  the  course  of  the  four-and-twenty  hours.  Our 
constant  care  should  be  to  keep  the  bowels  from  being  bound, 
and  to  avoid  purging. 

The  remedy  which,  next  to  venesection  and  purging,  has 
been  employed  most  frequently  in  acute  rheumatism,  is  opium. 
The  symptoms  of  the  disease  are  so  strikingly  indicative  of 
irritation  and  excitement,  and  are  accompanied  by  pain  so  con- 
stant and  severe,  that  the  tranquilizing  influence  of  opium 
seems  especially  called  for.  Accordingly  it  has  been  given  at 
every  period  of  the  disease,  sometimes  in  small,  sometimes  in 
very  large  doses.  I  believe  the  ordinary  practice  has  been  to 
administer  from  two  to  four  grains  in  the  course  of  four-and- 
twenty  hours,  premising  a  blood-letting,  and  acting  from  time 
to  time  upon  the  bowels  by  calomel  and  salts  and  senna.  This 
method  of  treatment  is  objectionable,  both  on  theoretical  and 
practical  grounds : — theoretically,  because  it  is  not  conducive 
to  the  elimination  of  the  rheumatic  poison ;  and  practically, 
because  it  fails  in  materially  alleviating  the  patient's  suffer- 
ings, and  in  shortening  their  duration.  In  moderate  doses, 
opium  has  not  the  slightest  influence  in  calming  the  nervous 
system  when  roused  and  excited  by  the  agency  of  acute  rheu- 
matic inflammation ;  there  is  then  so  much  of  action  and  of 
suffering,  that  I  have  known  four  grains  taken  daily  by  a  child 
only  ten  years  old,  without  the  production  of  any  sensible  effect 
beyond  that  of  somewhat  alleviating  his  sufferings  ;  and  if  this 
medicine  is  to  be  made  available  for  relief,  it  must  be  given  to 
adults  in  much  larger  doses. 


98  TREATMENT  OF  ACUTE  RHEUMATISM, 

Dr.  Cazenave,  of  Pau,  was  the  first  to  recommend  the  exhi- 
bition of  large  and  repeated  doses  of  opium  for  the  cure  of  acute 
rheumatism  ;  but  the  physician  to  whom  the  profession  in  this 
country  is  indebted  for  the  practice,  is  Dr.  Corrigan,  of  Dublin. 
He  generally  begins  with  a  grain  every  two  or  three  hours,  and 
recommends  that  the  dose  be  increased,  "  both  in  frequency 
and  'quantity,  until  the  patient  feels  decided  relief,  when  it 
should  be  kept  up  at  that  dose  until  the  disease  is  steadily  de- 
clining."^ The  average  quantity  required  in  twenty-four 
hours,  he  considers  to  be  about  twelve  grains ;  and  even  that 
quantity  does  not  affect  the  head.  Diarrhoea,  he  says,  some- 
times occurs  while  the  patient  is  using  the  opium  in  full  doses, 
and  purgatives  are  seldom  required.  In  one  case  no  less  than 
200  grains  were  taken  in  the  course  of  a  fortnight,  with  mani- 
fest relief. 

Of  this  method  of  treatment  I  cannot  speak  from  personal 
experience,  inasmuch  as  by  employing  other  medicines  in  con- 
junction with  opium,  I  have  seldom  been  obliged  to  make  use 
of  it  so  unsparingly.  But  I  can  testify  most  strongly  to  the 
value  of  the  sedative  in  full  and  repeated  doses ;  in  doses  far 
exceeding  in  amount  the  quantity  usually  administered.^  In 
the  early  and  most  painful  stage  of  the  disease,  occurring  in 
adults,  it  may  be  often  given  with  the  greatest  advantage  to 
the  extent  of  six  or  eight  grains  in  the  course  of  twenty-four 
hours ;  and  to  children  may  be  administered,  without  the  slight- 
est fear,  in  half-grain  doses,  repeated  every  three  or  four  hours. 
In  doses  such  as  these,  when  combined  with  the  treatment 
hereafter  to  be  mentioned,  I  have  never  seen  it  check  secretion, 
or  produce  the  slightest  cerebral  disturbance ;  rarely,  indeed, 
has  it  even  occasioned  sleep,  but  it  has  calmed  the  patient's 
irritability,  alleviated  his  sufferings,  and  has  thus  prevented 
the  wear  and  tear  of  the  system,  arising  from  a  long  and  painful 

1  "  Dublin  Medical  Journal,"  vol.  xvi,  p.  266. 

2  "  In  procuring  sleep  (and  allaying  pain)  opium  is  the  most  valuable  remedy 
we  possess,  and  its  use  is  not  to  be  measured  timidly  by  tables  of  doses,  but  by  the 
fulfillment  of  the  purpose  for  which  it  is  given."     (Holland's  "  Med.  Notes  ; "  cap. 

"  On  the  use  of  Opiates.") 


OR   RHEUMATIC   FEVER.  99 

illness.  More  than  this,  too,  I  believe  it  has  effected.  I  am 
satisfied  that  in  many  instances  it  has  materially  hastened  the 
period  of  convalescence,  and  has  lessened  the  frequency  of  in- 
flammation of  the  heart.  Therefore,  while  I  join  issue  with 
those  who  would  treat  acute  rheumatism  by  opium  alone,  I 
admit  most  fully  the  advantage  of  its  employment  in  conjunc- 
tion with  other  remedies,  and  in  quantity  sufficient  to  allay  or 
subdue  the  pain.  The  amount  required  for  this  purpose  varies 
in  different  cases,  and  is  dependent  not  only  upon  peculiar 
idiosyncrasies,  but  on  the  severity  of  the  disease  in  each  par- 
ticular instance,  and  the  treatment  previously  and  contempora- 
neously adopted.  In  cases  where  opium  is  employed  alone, 
about  twelve  grains  probably  may  be  required  to  subdue  the  pain 
and  pacify  the  excitement  of  the  nervous  system;  but  with  the 
aid  of  other  remedies,  six  or  eight  grains  are  usually  sufficient ; 
and  in  some  few  instances  our  object  may  be  attained  by  the 
exhibition  of  four  or  five  grains  only  in  the  course  of  four-and- 
twenty  hours.  Sure  am  I  that,  as  a  general  rule,  the  continu- 
ance of  pain  is  the  best  practical  test  of  the  propriety  of  its 
administration,  and  of  the  extent  to  which  its  exhibition  is  re- 
quired, and  that  whether  ten  or  two  grains  only  are  needed  in 
the  course  of  the  day,  it  may  be  given  with  impunity,  and, 
indeed,  with  advantage,  as  long  as  pain  and  restlessness  con- 
tinue.' I  know  of  nothing  to  contraindicate  its  use,  save  only 
the  suspension  of  secretion ;  and  I  am  aware  of  no  circumstance 
calculated  to  point  to  its  having  been  given  in  too  large  doses, 
except  the  supervention  of  stupor  or  narcotism.  On  neither 
of  these  points  is  there  the  least  cause  for  alarm.  The  latter 
symptom  will  never  arise  if  the  medicine  be  given  cautiously, 
and  its  operation  carefully  watched ;  and  observation  has  con- 
vinced me  that  it  suspends  secretion  in  exceptional  cases  only. 

1  "  When  given  for  the  relief  of  acute  pain  or  spasmodic  actions,  in  some 
parts  of  the  system,  it  would  seem  that  the  medicine,  however  vague  the  ex- 
pression, expending  all  its  specific  power  in  quieting  this  disorder  of  the  nervous 
system,  loses,  at  the  same  time,  every  other  influence  on  the  body.  Even  the 
sleep  peculiar  to  opium  appeai-s  in  such  instances  to  be  wanting,  or  produced 
chiefly  in  efTect  of  the  relief  from  suffering."  (Holland's  "  Medical  Notes  ;  "  cap. 
"  On  the  use  of  Opiates.") 


100  TREATMENT   OF   ACUTE   RHEUMATISM, 

Indeed,  it  appears  probable  that  opium,  when  given  in  quantity 
sufficient  to  subdue  the  pain  and  alhi}''  the  irritation,  so  far 
from  impeding  or  suspending  secretion,  conduces,  in  some  in- 
stances, to  its  promotion.  Certain  it  is,  that  in  the.  excited 
state  of  the  nervous  and  vascular  systems,  arising  from  the 
irritation  of  the  rheumatic  virus,  all  the  excretory  organs, 
except  the  skin,  perform  their  function  slowly  and  imperfectly  ; 
the  scanty  urine,  the  dark-colored  unhealthy  motions,  and  the 
coated  tongue,  testify  abundantly  to  this  important  fact ;  and 
equally  certain  is  it,  that  during  the  administration  of  opium 
the  urine  frequently  increases  in  quantity,  the  motions  become 
more  healthy  in  appearance,  and  the  coated  tongue  cleaner 
and  less  red.  So  that,  on  the  whole,  the  treatment  by  opium 
is  a  safer  and  better  plan  than  the  treatment  by  purgatives,  if 
the  bowels  have  been  acting  regularly,  and  still  continue  to  do 
so ;  but  the  treatment  by  purgatives  is  the  most  efficient  and 
most  certain,  if  the  bowels  have  been  previously  bound,  and 
still  show  a  disposition  to  be  confined. 

Venesection,  then,  calomel  combined  with  purgatives,  and 
opium,  are  the  three  remedies  which  have  been  most  generally 
made  use  of  for  the  cure  of  acute  rheumatism,  and  each,  in  its 
way,  has  been  found  conducive  to  the  well-being  of  the  patient. 
But  there  are  several  other  remedies  which  have  been  so  highly 
spoken  of,  and  so  extensively  used,  that  it  will  be  necessary  to 
advert  to  their  influence  on  this  disease  before  detailing  my 
method  of  treatment.  I  allude  to  vapor  and  hot-air  baths,  and 
to  mercury,  antimony,  cinchona,  colchicura,  guaiacum,  niter, 
lemon-juice,  alkalies,  and  their  salts. 

Forced  perspiration  has  been  always  much  in  vogue  as  a 
remedy  for  acute  rheumatism.  Formerly,  though  actually 
streaming  with  perspiration — the  acid  perspiration  so  charac- 
teristic of  the  disease — the  patient  was  made  to  swallow  large 
doses  of  antimony,  Dover's  powder,  and  other  sudorifics  ;  was 
placed  in  a  bed  covered  with  blankets,  subjected  to  the  heat  of 
hot  bottles  and  hot  bricks,  and  deluged  with  copious  draughts 
of  warm  drinks. 

In  modern  times,  though  not  so  carefully,  "  accinctus  ad 


OR   RHEUMATIC    FEVER.  101 

sudorem,"  the  unhappy  sufferer  has  been  sweated  quite  as  freely ; 
vapor  and  hot-air  baths  have  been  substituted  for  the  extra 
bed-clothes  and  hot  bottles,  and  guaiacura,  Dover's  powder,  and 
other  sudorifics  have  been  given  freely  and  repeatedly.  So 
copious  is  the  diaphoresis  thus  produced,  that  the  perspiration 
has  often  soaked  through  the  blankets  and  the  mattress,  and 
has  formed  a  pool  on  the  floor.  But  the  experience  of  all  ages 
is  against  the  adoption  of  this  method  of  treatment.  Sweated 
almost  beyond  belief,  and  exhausted  in  a  corresponding  degree, 
the  patient  obtains  very  little  relief  to  his  sufferings,  and  is  so 
much  reduced  in  strength,  that  he  is  frequently  afflicted  by  an 
eruption  of  sudamina,  recovers  slowly  and  imperfectly,  often 
experiences  a  relapse,  and  is  generally  subject  for  a  consider- 
able time  to  wandering  pains  in  the  limbs.  Repeated  observa- 
tion has  fully  convinced  me  of  the  inexpediency  of  this  method 
of  treatment,  except  in  cases  unaccompanied  by  free  perspira- 
tion. In  such  cases,  and  in  such  alone,  it  may  be  employed 
with  advantage,  but  even  then  it  should  be  omitted  directly  a 
free  and  natural  diaphoresis  has  been  established. 

Another  plan  of  treatment,  which  has  been  recommended  for 
the  cure  of  acute  rheumatism,  is  the  administration  of  mercury 
in  combination  with  opium,  so  as  to  produce  salivation.  In  my 
opinion,  however,  this  practice  is  not  only  unnecessary,  but 
decidedly  prejudicial  to  the  well-being  and  safety  of  the  patient. 
AVhen  given  so  as  to  affect  the  mouth,  mercury  proves  exceed- 
ingly depressing,  and  is  sometimes  productive  of  evil  conse- 
quences which  may  be  felt  for  months,  or  even  years.  More- 
over, it  exerts  no  perceptible  influence  over  the  rheumatic 
poison,  nor  does  it  assist  in  preventing  the  access  of  cardiac 
inflammation  ;  on  the  contrary,  I  have  repeatedly  observed, 
with  Dr.  Macleod,^  "  that  the  rheumatism  has  continued, 
although  the  mouth  was  affected,  while  it  has  speedily  subsided 
on  continuing  the  narcotic  and  purgatives  without  the  mer- 
curial." Moreover,  pericarditis  and  endocarditis  supervene  as 
readily  while  the  patient  is  under  the  influence  of  mercury  as 
when  that  drug  has  not  been  administered ;  and  when  such  is 

1  Ou  "Rheumatism,"  p.  360. 


102  TREATMENT   OF   ACUTE   RHEUMATISM, 

the  case,  we  lose  the  most  valuable  property  of  mercury,  namely, 
that  of  limiting  the  effusion  of  lymph  on  the  inflamed  surfaces 
of  the  heart.  Such  being  the  case,  mercurial  action  should 
never  be  induced  as  a  cure  for  an  uncomplicated  attack  of  acute 
rheumatism. 

M.  Laennec  was  a  strong  advocate  for  the  administration  of 
tartar  emetic  in  full  and  repeated  doses.  He  says,  "  there  is 
no  inflammation,  except  inflammation  of  the  lungs,  in  which 
tartar  emetic  is  more  eflScacious  than  in  articular  rheumatism. 
The  medium  duration  of  the  disease,  under  the  influence  of  this 
remedy,  is  from  seven  to  eight  days;  and  we  know  that  it  con- 
tinues from  one  to  two  months  under  the  treatment  of  blcedino-, 
or  of  '  la  mdthode  expectante.'  "  ^ 

Now,  admitting  most  fully  the  eflScacy  of  this  medicine  as  an 
auxiliary  to  other  remedies,  I  cannot  recommend  its  adminis- 
tration by  itself  as  a  remedy  for  acute  rheumatism.  Valuable 
as  arc  its  powers  in  moderating  local  action,  it  is  insuflicicnt  of 
itself  to  fulfill  the  conditions  essential  to  a  safe  and  speedy  cure 
of  the  disease.  And  not  only  so.  More  extended  observations 
have  not  tended  to  verify  the  extraordinary  curative  powers 
ascribed  to  it  by  M.  Laennec;  still  less  have  they  discovered 
in  what  manner  any  curative  influence  is  exerted.  That  its 
virtue  is  independent  of  its  action  as  a  diaphoretic  or  diuretic, 
is  fully  admitted  by  M.  Laennec,  who,  while  eulogizing  its 
power  of  subduing  the  articular  inflammation  and  effusion, 
suggests  that  it  acts  by  "promoting  the  activity  of  the  intersti- 
tial absorption,  more  especially  when  there  exists  in  the  economy 
an  excess  of  energy,  of  tone,  or  of  plethora."  Whatever  its 
mode  of  action,  however,  its  eflScacy  is  displayed  most  strikingly 
in  the  cases  here  alluded  to  by  M.  Laennec  ;  and,  therefore,  in 
the  young,  the  active,  and  plethoric,  in  whom  it  serves  to  obvi- 
ate the  necessity  for  bleeding  or  other  antiphlogistic  measures, 
it  may  be  employed  in  conjunction  with  remedies  having  more 
decidedly  curative  properties.  But  to  the  more  weakly,  and  to 
those  whose  symptoms  are  less  acute,  it  often  proves  extremely 

1  "Traite  des  Maladies  des  Poumons  et  du  Coeur,"  ed.  2,  p.  512. 


OR    RHEUMATIC   FEVER.  103 

depressing,  and  as  it  is  unnecessary  for  the  relief  of  the  local 
inflammation,  recourse  should  seldom  be  had  to  its  adminis- 
tration. 

The  administration  of  bark  in  acute  rheumatism  is  contrary 
alike  to  analogy  and  to  experience.  It  is  inconsistent  with  the 
active  nature  of  rheumatic  inflammation  :  it  is  contraindicated 
by  the  intensity  of  the  febrile  disturbance,  by  the  full  and 
bounding  pulse,  the  furred  tongue,  and  the  loaded  urine ;  and 
it  is  forbidden  by  the  marked  aggravation  of  the  symptoms 
which  usually  follows  its  incautious  exhibition.  It  has  never- 
theless been  so  well  spoken  of  by  men  whose  recommendation 
is  deserving  of  attention,^  that  it  may  be  right  to  examine 
somewhat  in  detail  the  history  of  the  cases  on  which  such 
favorable  opinions  have  been  founded. 

Dr.  Haygarth,  one  of  the  most  strenuous  advocates  of  this 
method  of  treatment,  was  in  the  habit  of  giving  doses  of  from 
ten  to  thirty  grains  of  the  powder,  or  from  an  ounce  and  a  half 
to  two  ounces  of  the  decoction  of  bark,  three  or  four  times  a 
day.  He  generally  began  to  give  it  between  the  third  and 
tenth  day  of  the  attack,  at  a  time  when  the  articular  inflam- 
mation was  most  acute,  and  was  accompanied  by  active  febrile 
disturbance.  Yet,  he  says,  "  I  can  only  discover  five  instances 
in  which  the  bark  did  not  produce  manifest  salutary  eff"ects  on 
its  first  exhibition."  ^  No  opinion  can  be  more  decided,  or  more 
favorable  to  the  influence  of  the  remedy,  and  none  certainly 
can  be  in  more  direct  opposition  to  the  result  of  modern  expe- 
rience. Fortunately,  therefore,  he  has  given  to  the  world  a 
record  of  the  cases  on  which  his  favorable  opinion  is  based,  and 
from  these  very  cases  it  is  difficult  to  arrive  at  any  other  than 
an  opposite  conclusion.  Out  of  the  170  cases  of  acute  rheu- 
matism which  he  has  recorded,  49  were  treated  by  salines,  anti- 
monials,  purgatives,   and  bleeding,  while  the  remaining   121 

*  The  cinchona  was  extensively  used  by  Dr.  Haygarth,  at  the  latter  end  of 
the  last  century,  and  has  been  sanctioned  by  the  testimony  of  Dr.  Fothergill, 
Dr.  Heberden,  Sir  George  Baker,  Sir  Walter  Farquhar,  and  other  physicians  of 
experience  and  reputation. 

*  "Clinical  History  of  Disease,"  p.  108. 


•104  TREATMENT    OF    ACUTE    RHEUMATISM, 

were  treated  more  or  less  completely  by  bark.  Out  of  the 
whole  number,  19^  had  symptoms  of  "  phrenitis"  and  "deli- 
rium," and  of  these  19  cases,  no  less  than  17  were  met  with 
among  those  to  whom  the  cinchona  Avas  administered,  a  fact 
which  affords  a  fearful  commentary  upon  this  inconsistent  and 
empirical  method  of  treatment. 

In  my  own  practice,  bark  has  never  been  given  at  such  an 
early  period  of  the  disease,  nor  have  I  often  seen  it  so  admin- 
istered by  others ;  but  I  have  repeatedly  watched  its  adminis- 
tration at  a  later  period,  while  the  tongue  has  still  continued 
furred,  and  the  pulse  excited;  and  it  has  been  so  constantly 
followed  by  a  fresh  accession  of  mischief,  that  I  have  been 
deterred  from  making  use  of  it  until  the  urine  has  cleared,  the 
pulse  has  become  soft,  and  the  tongue  moist  and  almost  clean. 
Then,  more  especially  in  cachectic  states  of  constitution,  or  in 
persons  who  have  been  much  exhausted  by  the  attack,  it  is 
often  of  essential  service ;  but  even  under  these  circumstances 
its  effects  must  be  carefully  watched,  in  order  that  its  adminis- 
tration may  be  abandoned  at  once,  should  any  increased  heat 
of  skin,  acceleration  of  the  pulse,  or  coating  of  the  tongue  or 
loading  of  the  urine  appear  to  indicate  a  recurrence  of  fever. 
Indeed,  it  is  only  in  the  very  weakly  and  cachectic  that  it  is 
ever  advisable  to  have  recourse  to  its  employment,  for  in  the 
great  majority  of  instances  quinia  is  more  readily  and  earlier 
tolerated ;  and  as  it  is  quite  as  efficient  as  bark,  it  should  have 
the  preference  when  an  eruption  of  sudamina,  the  character  of 
the  pulse,  or  the  cleaning  of  the  tongue  appears  to  demand  or 
admit  of  the  exhibition  of  a  tonic.  It  should  be  used  as  a  cor- 
rective and  restorative  of  the  processes  of  assimilation  when 
the  febrile  paroxysm  is  beginning  to  abate,  rather  than  as  a 
cure  during  the  active  stages  of  the  disease. 

Colchicum  is  a  medicine  which  has  been  lauded  as  much  too 
extravagantly  by  one  class  of  practitioners,  as  it  has  been 
abused  too  indiscriminately  by  another.  By  some  it  has  been 
called  a  specific  for  acute  rheumatism,  and  by  such  has  been 

^  In  column  ix  of  Dr.  Hajgarth's  tables,  sixteen  cases  only  are  menlioned, 
but  three  others  are  to  be  found  in  column  xvi. 


OR    RHEUMATIC   FEVER.  105. 

exclusively  relied  on  for  its  cure ;  and  in  proof  of  its  eflScacy, 
cases  have  been  adduced  in  which  not  only  has  the  disease  dis- 
appeared under  its  influence,  but  its  subsidence  has  been 
accompanied  by  profuse  evacuations  from  the  kidneys,  the 
stomach,  or  the  liver,  and  bowels.  The  pain  has  abated,  and 
the  pulse  has  become  more  tranquil,  coincidently  with  the 
occurrence  of  purging,  or  vomiting,  or  diuresis.^ 

In  stating  these  facts,  I  am  saying  all  that  can  be  said  in 
favor  of  colchicum  administered  alone  for  the  cure  of  acute 
rheumatism.  All  practitioners  will  admit,  that  when  it  causes 
purging  or  vomiting,  or  excites  an  abundant  flow  of  urine,  it 
may  possibly  of  itself  efi"ect  a  cure ;  but  few,  I  think,  are  dis- 
posed to  ascribe  to  it  a  curative  power  except  under  these  con- 
ditions. Purging  and  vomiting,  however,  are  among  the  first 
symptoms  of  poisoning  by  colchicum,  and  are  often  accompanied 
by  such  extreme  prostration,  and  by  so  much  gastro-intestinal 
irritation,  that  Avhen  it  becomes  a  question  whether  the  cure  of 
the  disease  can  be  safely  intrusted  to  colchicum  alone,  the  pru- 
dent physician  very  properly  hesitates  in  recommending  or 
adopting  so  dangerous  an  expedient.  He  refuses  to  rely  solely 
upon  a  medicine  which  is  apt  to  produce  such  disagreeable 
effects,  and  tries  to  discover  some  method  by  which  he  may 
obtain  from  it  its  virtue  as  a  remedy,  without  running  the  risk 
of  its  action  as  a  poison. 

Now  this  may  be  effected  by  administering  it  in  small  doses 
in  combination  with  other  medicines  ;  and  although  in  this  form 
it  may  not  have  the  power  of  curing  acute  rheumatism,  it  has 
at  least  the  property  of  alleviating  its  symptoms,  and  shorten- 
ing their  duration.  It  does  so,  I  believe,  not  by  operating 
simply  as  a  sedative,  nor  by  acting  specifically  upon  the  rheu- 
matic virus,  but  by  promoting  its  evacuation  by  the  kidneys, 
and  by  exercising  some  influence  over  the  process  of  assimila- 
tion, whereby  the  formation  of  the  poison  is  checked.  Be  this 
as  it  may,  immediate  benefit  so  repeatedly  results  from  its 
administration  in  conjunction  with  small  doses  of  calomel, 
ipecacuanha,  alkalies,   and  opium,  and   in  chronic  cases  is  so 

1  See  "London  Med.  Gazette,"  June  30,  1838. 


106         TREATMENT  OF  ACUTE  RHEUMATISM, 

frequently  obtained  bj  its  administration  uncombinod  with 
other  remedies,  and  in  doses  insufficient  to  produce  any  sensible 
eJGTect  upon  particular  organs,  that  no  one  can  hesitate  to  assign 
to  it  the  improvement  in  the  instances  alluded  to. 

But  it  is  not  equally  beneficial  in  all  cases  of  acute  rheuma- 
tism, nor  in  all  forms  nor  at  all  stages  of  the  complaint.  It 
is  far  less  efficacious  in  the  weak  and  nervous,  than  in  the  more 
robust  and  less  easily  depressed,  and  of  less  value  in  purely 
fibrous  rheumatism,  than  in  cases  complicated  by  synovial 
inflammation.  In  my  hands,  too^  it  has  proved  less  advan- 
tageous in  proportion  as  the  fever  has  exceeded  the  articular 
swelling,  and  as  the  urine  has  been  less  highly  charged  with 
the  lithates. 

But  though  colchicum  is  of  the  greatest  value  in  the  treat- 
ment of  acute  rheumatism,  its  operation  must  be  Avatched  most 
carefully.  Throughout  its  administration  it  is  impossible  to 
insist  too  strongly  upon  the  necessity  of  securing  a  daily  evac- 
uation from  the  bowels,  and  of  attending  to  the  other  general 
symptoms  of  the  disease.  If  the  lithates  disappear  from  the 
urine,  if  the  pulse  becomes  weak,  if  faintness,  or  nausea,  or 
purging  supervenes,  its  use  must  be  instantly  discontinued. 
But  until  some  one  of  these  symptoms  occurs,  a  grain  or  a 
grain  and  a  half  of  the  acetous  extract  or  the  inspissated  juice, 
or  from  fifteen  to  twenty  minims  of  the  wine  of  colchicum,  may 
be  administered  safely,  and  with  obvious  advantage,  two  or 
three  times  a  day. 

Of  guaiacum  I  have  had  considerable  experience.  I  have 
seen  it  administered  by  my  colleagues  at  St.  George's  Hos- 
pital, sometimes  alone,  sometimes  in  conjunction  with  other 
remedies,  in  a  large  number  of  cases,  and  I  have  myself  pre- 
scribed it  on  several  occasions  with  some  apparent  advantage. 
Observation,  however,  has  not  led  me  to  form  a  very  favorable 
estimate  of  its  curative  power  in  this  particular  form  of  the 
disease.  In  persons  of  a  weakly,  broken-down  constitution, 
and  in  subacute  cases  unaccompanied  by  the  characteristic  acid 
perspiration,  it  has  sometimes  proved  of  essential  service  in 
stimulating  the  action  of  the  skin  ;  but  in  most  acute  cases,  if 


OR    RHEUMATIC    FEVER.  107 

it  has  done  no  harm,  it  has  eifected  little  good  as  compared 
with  other  remedies :  it  has  neither  appeared  to  mitigate  the 
symptoms,  nor  to  shorten  their  duration. 

There  is,  however,  as  much  diiTerence  in  regard  to  the  action 
of  this  medicine  in  different  cases,  and  in  different  doses,  as 
there  is  in  regard  to  colchicum.  Dr.  Seymour,  who  was  in  the 
habit  of  giving  the  raistura  guaiaci  of  the  "Pharmacopoeia"  in 
full  and  repeated  doses,  says :  "  It  acts  not  as  a  stimulant,  but 
as  an  evacuant,  provoking  purging,  perspiration,  and  a  flow  of 
urine  in  a  very  violent  manner :  sometimes  one,  sometimes  all 
these  effects  follow  the  use  of  the  medicine."^  Now,  in  my 
experience,  the  beneficial  effects  of  guaiacum  in  the  acute  dis- 
ease are  observed  precisely  under  the  conditions  pointed  out 
by  Dr.  Seymour ;  they  are  obtained  in  those  cases,  and  in 
those  alone,  which  are  unaccompanied  by  perspiration,  and  in 
which  the  excretory  organs  are  greatly  excited  by  the  action 
of  the  remedy.  But  in  ordinary  doses,  and  under  ordinary 
circumstances,  when  the  patient  is  perspiring  freely,  and  when 
it  neither  purges  nor  causes  diuresis,  very  little  benefit  results 
from  its  employment.'  It  neither  modifies  the  local  action  nor 
limits  its  duration ;  and  as  the  purging  induced  by  its  opera- 
tion is  sometimes  most  distressing,  its  exhibition  should  be 
reserved  for  subacute  or  lingering  cases,  in  which,  when  it  pro- 
vokes a  free  perspiration,  its  beneficial  influence  cannot  be 
doubted. 

The  nitrate  of  potash  has  been  largely  employed  for  the  cure 
of  acute  rheumatism,  both  in  this  country  and  on  the  Continent, 
in  doses  varying  from  a  few  grains  to  two  or  even  four  drachms 
three  or  four  times  a  day.  In  the  smaller  quantities  I  have 
frequently  given  it  in  combination  with  other  remedies  ;  and 
on  several  occasions  I  have  seen  it  administered  to  the  extent 
of  an  ounce  in  the  course  of  four-and-twenty  hours.  Generally, 
it  has  been  without  obvious  action  on  the  excretory  organs,  and 
has  exerted  little  influence  over  the  intensity  of  the  symptoms, 
or  the  duration  or  ultimate  issue  of  the  disease. 

•  Clinical  Lectures,  published  in  the  "Medical  Gazette,"  and  the  "  Medico- 
Chir.  Review,"  vol.  xxxiii. 


108  TREATMENT    OF   ACUTE   EHEUMATISM, 

Mons.  Gendrin  in  France,  and  Dr.  Basham  in  tliis  country, 
have  been  lately  adopting  the  practice  recommended  by  Dr. 
Brocklesby,  in  1764/  of  giving  large  and  repeated  doses  of 
this  salt.  Dr.  Henry  Bennett  speaks  most  favorably  of  its 
efficacy  as  administered  by  Mons.  Gendrin  at  the  Hospital  of 
La  Piti^.  He  states  that  the  salt,  Avhen  properly  administered, 
"is  from  the  first  tolerated  in  the  great  majority  of  cases," 
but  that  sometimes  "the  injection  of  the  solution  occasions 
•slight  vomiting."  During  the  first  twenty-four  or  thirty-six 
hours,  very  little  change  is  produced  in  the  state  of  the  patient ; 
but,  generally  speaking,  about  that  time,  sometimes  a  little 
later,  the  pulse  diminishes  in  strength  and  number,  and  that 
■without  any  perceptible  change  in  the  state  of  the  patient. 
He  has  "  seen  many  cases  in  which  the  renal  secretion  has 
been  decidedly  increased,  and  sometimes  the  excretions  of  the 
skin  are  also  much  increased ;"  and  "  when  this  occurs,  he  has 
remarked  that  the  pulse  falls  much  more  rapidly  than  when 
the  depressing  effect  of  the  salt  is  alone  experienced."^  Dr. 
Basham  also  speaks  highly  of  its  value  when  freely  admin- 
istered. "  One,  two,  or  even  three  ounces  of  it,  freely  diluted, 
may"  he  says  "be  taken  in  the  twenty- four  hours  in  cases  of 
acute  rheumatism,  and  in  the  majority  of  cases  without  pro- 
ducing any  obvious  effect  on  the  force  or  frequency  of  the 
pulse,  the  integrity  of  the  digestive  function,  the  state  of  the 
abdominal  organs,  or  even  upon  the  quantity  of  urine  excreted," 
'but  "  it  relieves  in  a  marked  manner  the  swelling,  heat,  and 
pain  of  the  joints."  He  has  "  never  seen  the  nitrate  of  potash, 
in  large  or  small  doses,  produce  either  nausea  or  vomiting.^ 

»  ''  Medical  Observations,"  by  Dr.  Richard  Brocklesby,  8vo. ;  London,  1764. 
The  Doctor  states  "  that  for  diet  and  sustenance,  the  patient  should  be  con- 
fined to  the  free  use  of  ■vcater-gruel,  in  each  quart  of  which  two  drachms  of 
niter  were  to  be  dissolved,  and  when  the  stomach  would  allow  the  quantity 
of  drink,  two  drachms  or  more  of  niter  would  be  taken  in  the  four-and- 
twenty  hours.  It  usually  caused  free  perspiration,  and  acted  sufficiently  as 
an  aperient,  and  when  it  failed  in  this  respect,  the  help  of  injections  was 
added." 

2  On  the  Treatment  of  .Acute  Rheumatism  by  large  doses  of  Nitrate  of  Pot- 
ash.    ("Lancet"  for  1844,  vol.  i,  p.  374.) 

'  Such  symptoms  nevertheless  do  sometimes  occur.  Dr.  Robert  Barnes 
reports  that  "  in  one  case  which  he  watched  in  the  wards  of  M.  Gendrin,  alarm- 


OR    RHEUMATIC    FEVER.  109 

In  a  few  cases  pinching  or  griping  pains  of  the  abdomen,  with 
a  few  watery  evacuations,  which  have  quickly  ceased  on  dis- 
continuing the  salt,  are  the  only  unpleasant  or  undesirable 
effects  which  he  has  witnessed."^ 

Now  I  heartily  wish  I  could  confirm  this  favorable  report  of 
the  curative  action  of  nitrate  of  potash,  but  such,  unfortunately, 
is  not  the  case.  I  have  watched  its  administration  to  the 
extent  of  about  an  ounce  daily,  in  seventeen  cases  of  acute 
rheumatism,  and  to  a  smaller  extent  in  several  others,  and  in 
one  instance  only  did  it  appear  to  exercise  any  decided  con- 
trol over  the  course  or  duration  of  the  symptoms.  In  most 
instances  it  was  readily  tolerated  by  the  stomach  ;  and  in  the 
case  alluded  to  gave  rise  to  copious  diuresis,  with  manifest 
relief  to  the  pain  and  inflammation  ;  but  in  every  other  instance 
it  was  without  any  obvious  effect  upon  the  excretions,  and  the 
disease  continued  of  average  intensity,  and  ran  on  to  its  ordi- 
nary duration.  Indeed,  in  the  cases  reported  by  Dr.  Basham, 
the  patients  on  the  average  were  four  weeks  and  a  half  under 
treatment,  and  as  application  is  seldom  made  to  a  hospital 
until  the  patients  have  been  ill  some  days  at  home,  the  average 
duration  of  the  cases  alluded  to  can  hardly  have  been  less  than 
five  or  six  weeks,  which  is  a  period  of  quite  the  average  dura- 
tion. But  as  niter,  contrary  to  the  observation  of  Dr.  Basham, 
does  appear  to  exercise  a  powerful  influence  over  the  vascular 
system,^  diminishes  the  force  and  frequency  of  the  heart's 
action,  and  controls  the  tendency  to  fibrinous  deposition  by 
increasing  the  solubility  of  the  fibrin,  it  is  valuable  in  acute 
rheumatism,  not  so  much  by  effecting  a  cure  of  the  disease,  as 
by  tending  to  prevent  those  untoward  complications  which 
render  it  so  formidable. 

Lemon-juice,  in  one  or  two  ounce  doses,  repeated  three  or 

ing  diarrhcca  supervened  on  the  second  day,  together  with  vomiting  and  pain 
on  pressure  over  the  region  of  the  stomach,  and  increase  of  febrile  move- 
ment."    ("  Lancet"  for  1844,  p.  472.) 

1  On  the  Nitrate  of  Potash  in  Acute  Rheumatism.  ("  Med.-Chir.  Trans.," 
vol.  xxxii,  pp.  5,  6.) 

■■^  Mr.  Alexander  found  by  experiment,  that  niter  most  surprisingly  and  most 
rapidly  diminishes  the  frequency  of  the  heart's  pulsations.  {Vide  ''Essays," 
p.  105,  et  seq.) 


110         TREATMENT  OF  ACUTE  RHEUMATISM, 

four  times  a  day,  was  introduced  as  a  cure  for  acute  rheuma- 
tism by  Dr.  Owen  Rees.  He  supposed  that,  by  the  excess  of 
oxygen  it  contains,  it  promotes  the  conversion  of  lithic  acid 
into  urea  and  carbonic  acid,  and  thereby  favors  its  excretion 
from  the  system,  while  the  small  quantity  of  alkaline  citrate 
which  it  contains,  contributes  also  in  some  measure  toward 
effecting  a  cure.  A  more  plausible  explanation  appears  to  me 
to  be  that  its  curative  effect  depends  upon  its  supplying  a 
necessary  material  to  the  blood  and  promoting  the  oxidation  of 
lactic  acid,  and  its  conversion  into  carbonic  acid.  Whatever 
its  mode  of  action,  however,  the  remedy  had  the  advantage 
both  of  simplicity  and  novelty,  and  accordingly  for  some  time 
was  very  generally  adopted.  But  after  an  ample  trial  it  has 
now  been  discarded  as  uncertain  in  its  action ;  and  physicians 
are  again  content  to  rely  upon  a  more  rational,  though  more 
complex,  method  of  treatment. 

The  advantages  claimed  for  this  remedy  by  Dr.  Owen  Rees, 
are  power  to  moderate  vascular  action  and  to  afford  speedy 
relief  to  the  rheumatic  symptoms.  Judging,  however,  from 
my  limited  experience,  I  cannot  conscientiously  speak  of  these 
effects  as  the  ordinary  results  of  its  administration.  I  have 
watched  its  exhibition  in  twenty-nine  patients,  and  although  in 
several  it  produced  much  depression,  in  some  gave  rise  to 
griping  pains  in  the  abdomen,  and  in  one  excited  violent  diar- 
rhoea, accompanied  by  a  copious  discharge  of  blood  from  the 
bowels,  yet  in  three  patients  only  did  it  appear  to  afford  relief, 
or  to  hasten  recovery. 

In  the  three  instances  alluded  to,  it  was  taken  in  full  doses, 
viz.,  eight  ounces  in  the  twenty-four  hours,  and  was  not  only 
tolerated,  but,  as  far  as  I  could  judge,  was  speedily  assimilated 
in  the  stomach  ;  and  its  influence  in  quieting  the  heart's  action, 
in  promoting  a  free  evacuation  from  the  kidneys,  and  in  caus- 
ing subsidence  of  the  articular  inflammation,  was  very  marked. 
But  in  most  cases  it  did  not  appear  to  be  readily  digested,  as 
was  evidenced  by  the  length  of  time  which  elapsed  before  the 
patient  became  free  from  its  flavor  ;  and  it  is  probable  that  its 
frequent  failure   in   alleviating  the  symptoms  of  the  disease 


OR    RHEUMATIC    FEVER.  Ill 

may  be  attributed  in  part  to  this  cause,  and  in  part  to  the  fact 
that  the  blood  in  many  cases  requires  materials  which  lemon- 
juice  does  not  contain  or  is  not  capable  of  supplying.  Be  this 
as  it  may,  the  results  of  its  administration  were  anything  but 
encouraging.  And  on  analyzing  the  cases  reported  by  Dr. 
Rees,  I  do  not  find  that  he  has -obtained  a  much  more  favorable 
result ;  for,  on  the  average,  his  cases  were  twenty-five  days 
under  treatment,  and  were  ill  for  a  period  of  forty  days,  a  term 
within  which  the  symptoms  will  have  subsided,  and  health  will 
have  been  restored  under  most  methods  of  treatment.  There- 
fore, without  denying  that  lemon-juice  may,  in  some  instances, 
prove  beneficial,  I  would  not  generally  recommend  its  employ- 
ment. If  alkalies  and  the  neutral  salts  cannot  be  given  in  full 
doses,  in  consequence  of  their  being  rejected  by  the  stomach, 
and  if  other  treatment  fails  in  its  object,  then  perhaps  lemon- 
juice  may  be  tried  ;  but  it  is  less  efficacious  in  curing  the  patient, 
and  relieves  his  suff'erings  far  less  certainly  and  speedily  than 
does  the  treatment  I  ordinarily  pursue. 

But  thouorh  I  do  not  counsel  the  administration  of  lemon- 

O 

juice  as  a  medicine  on  which  to  rely  for  the  cure  of  acute  rheu- 
matism, I  am  of  opinion  that  numerous  instances  occur  in  which 
its  influence  may  be  beneficially  exerted  in  aid  of  other  remedies. 
Many  persons  adopt  a  diet  which  is  apt  to  lead  to  a  deficiency 
of  vegetable  acid  in  the  system,  and  whenever  there  is  reason 
to  suspect  such  a  deficiency,  I  order  lemonade  to  be  taken  as  a 
beverage,  while  the  disease  is  being  combated  by  other  means. 
Nor  have  I  ever  had  occasion  to  regret  its  administration,  under 
the  conditions  referred  to,  for  it  has  generally  proved  grateful 
to  the  patient,  and  apparently  serviceable  in  checking  the  dis- 
ease. And  although  if  given  indiscriminately  it  often  fails  in 
affording  relief,  it  seldom  does  harm  or  occasions  discomfort, 
unless  it  disagrees  with  the  stomach,  in  which  case  its  use  must 
be  discontinued. 

Of  the  value  of  alkalies  and  their  salts  in  acute  rheumatism, 
it  is  impossible  to  speak  too  highly.  Whether  regard  be  had 
solely  to  the  facts  that  the  normal  alkalinity  of  the  saliva  dis- 
appears, that  the  acidity  of  the  perspiration  is  excessive,  that 


112         TREATMENT  OF  ACUTE  RHEUMATISM, 

the  urine  is  surcharged  with  acid,  and  that  the  alvine  dejections 
are  also  loaded  with  acidulous  matters ;  I  say,  whether  regard 
be  had  solely  to  these  significant  facts,  or  whether  the  question 
be  viewed  in  reference  to  the  occurrence  of  fibrinous  deposits  on 
the  valvular  apparatus  of  the  heart,  alkalies  in  either  case  cannot 
fail  to  prove  useful.  They  are  not  only  active  depurating  agents, 
and  corrective  of  the  abnormal  condition  of  the  blood  and  excre- 
tions, but,  in  great  measure,  they  are  preventive  of  the  depo- 
sition of  fibrin.'  Administered  alone,  however,  and  in  ordinary 
doses,  they  are  inadequate  to  efl'ect  a  speedy  cure.  The  system 
is  so  surcharged  with  acid,  that  no  ordinary  doses  can  restore 
its  alkalinity ;  and  even  when  given  in  doses  sufficient  to  effect 
this  purpose,  alkalies  in  many  cases  prove  unequal  to  restore  a 
healthy  state  of  assimilation,  and  to  prevent  the  further  forma- 
tion of  acid  in  the  system.  Of  this  I  am  fully  satisfied  by  ex- 
perience. The  pain  may  be  greatly  alleviated,  and  the  force 
of  the  febrile  and  inflammatory  symptoms  checked,  but  no  cer- 
tainty can  be  felt  as  to  arresting  the  disease  without  the  aid  of 
other  medicines  to  assist  in  modifying  the  function  of  assimila- 
tion, and  to  act  on  the  various  excretory  organs.. 

It  will  be  gathered  from  what  has  been  already  stated,  that 
my  chief  objection  to  many  of  the  expedients  which  have  been 
resorted  to  for  the  cure  of  acute  rheumatism,  lies  not  so  much 
against  the  remedies  themselves,  as  against  the  mode  in  which 
they  have  been  employed.  Each  remedy  or  class  of  remedies 
has  been  too  exclusively  relied  upon.  There  may  be  occasions 
in  which  blood-letting  or  opium,  or  calomel  and  active  purging, 
are  necessary ;  there  may  be  circumstances  which  call  for  the 
exhibition  of  guaiacum,  niter,  colchicum,  or  other  agents  ;  but 
it  seldom  if  ever  happens  that  the  cure  of  acute  rheumatism 
can  be  safely  intrusted  to  any  single  remedy.  For  as  the  dis- 
ease presents  different  aspects  in  different  cases,  so  does  it  also 
at  different  stages  in  the  same  individual ;  and  even  were  it 
not  so,  the  constitutional  disturbance  is  so  great,  the  cause  of 
the  derangement  is  so  widely  spread,  and  its  effects  extend  to 

*  See  Simon's  "  Chemistry,"  in  "  Sydenham  Society's  Publications,"  pp. 
116-17. 


OR    RHEUMATIC    FEVER.  113 

such  a  variety  of  organs,  that  every  principle  of  medicine  points 
to  a  compound  method  of  treatment  as  most  likely  to  lead  to  a 
successful  issue. 

The  treatment  to  which  I  usually  have  recourse  at  the  outset 
of  the  attack,  is  that  alluded  to  at  the  beginning  of  this  chapter. 
It  is  made  up  of  alkalies  and  the  neutral  salts,  with  colchicum, 
opium,  and  if  necessary,  calomel.  Sometimes  a  little  antimony 
is  added,  sometimes  the  aid  of  purgatives  is  had  recourse  to, 
and  occasionally,  though  rarely,  I  deem  it  expedient  to  premise 
a  moderate  blood-letting.  Baths  are  never  employed  if  the  skin 
is  acting  freely ;  but  if,  insteiad  of  being  bathed  in  perspiration, 
it  remains  dry  and  hot,  and  burning,  I  then  endeavor  to  stimu- 
late its  action  by  means  of  the  vapor  or  hot-air  baths. 

As  venesection,  if  employed  at  all  in  acute  rheumatism,  is 
to  be  made  use  of  with  a  view  of  producing  an  impression  on 
the  train  of  morbid  actions,  and  expediting  the  operation  of 
other  remedies,  it  must  necessarily  take  the  lead  of  all  other 
measures ;  and  the  first  question  to  be  decided,  therefore,  in 
every  case  of  acute  rheumatism,  is  as  to  the  propriety  of  having 
recourse  to  its  employment.  It  has  been  already  pointed  out, 
that  the  use  of  the  lancet  is  not  necessary  for  the  relief  of  the 
pain  or  the  tranquilization  of  the  pulse,  and  that  in  the  pale 
and  weakly  it  exercises  an  influence  prejudicial  to  the  patient 
by  rendering  more  irritable  his  already  irritable  and  excited 
heart.  But  in  the  young,  plethoric,  and  robust,  in  whom  secre- 
tion is  insufficient,  whose  pulse  is  full  and  bounding,  and  whose 
skin  is  dry  and  hot,  and  burning,  it  certainly  does  assist  in 
expediting  the  action  of  other  remedies,  and, so  in  promoting 
recovery.  These,  therefore,  are  the  only  cases  in  which  it 
should  be  employed,  and  a  single  bleeding  of  from  eight  to  ten 
ounces  is  generally  sufficient.  It  relieves  that  excessive  con- 
gestion on  which  the  want  of  secretion,  in  great  measure, 
depends,  and  which  forms  an  obstacle  to  the  action  of  those 
remedies  on  which  we  rely  for  effecting  a  cure. 

The  next  point  is  as  to  the  expediency  of  giving  calomel  and 
purgatives.  If  the  bowels  are  acting  once  a  day,  it  is  seldom 
necessary  to  make  a  more  frequent  call  upon  their  activity,  but 


114         TREATMENT  OF  ACUTE  RHEUMATISM, 

a  dose  of  calomel  and  opium  may  be  prescribed  with  the  view 
of  modifying  the  character  of  their  secretions.  If  the  bowels 
are  sluggish  in  their  action,  and  the  dejections  dark  colored 
and  offensive,  a  dose  of  calomel  combined  with  opium  should  be 
administered  at  once,  and  followed,  after  the  lapse  of  six  or 
eight  hours,  by  a  draught  containing  the  infusion  of  senna,  toge- 
ther with  half  an  ounce  of  the  potassio  tartrate  of  soda,  and 
twenty  minims  of  the  vinum  colchici.  And  the  amount  of  opium 
should  be  so  adjusted  to  the  dose  of  the  purgative  as  to  procure 
one  full  and  copious  evacuation  without  the  distress  attendant 
upon  purging. 

When  once  the  bowels  have  been  freely  acted  on,  the  state 
of  the  secretions  must  be  our  guide  as  to  the  repetition  of  the 
calomel  and  the  morning  laxative.  If  the  tongue  be  rather 
dry ;  if  the  bowels  continue  sluggish,  and  the  dejections  dark 
colored  and  offensive,  the  mercurial  and  the  purgative  should 
be  repeated  for  several  successive  days.  If,  on  the  other  hand, 
secretion  from  the  bowels  be  healthy,  the  further  exhibition  of 
mercury  is  unnecessary.  If,  again,  the  secretions  be  copious 
but  unhealthy  in  character,  the  calomel  and  opium  should  be 
repeated  at  night,  but  need  not  be  followed  by  a  purgative  in 
the  morning,  as  after  one  or  two  doses  of  the  mercurial,  the 
motions  become  lighter  colored,  more  bilious  in  appearance, 
and  of  a  less  offensive  character. 

While  the  state  of  the  intestinal  secretions  are  thus  attended 
to,  alkalies  and  the  neutral  salts  should  be  administered  in  full 
doses  in  combination  with  a  few  drops  of  colchicum  wine.  In 
some  instances  ^he  addition  of  opium  is  necessary,  in  others  a 
little  antimony  is  useful.  At  one  time  I  used  to  content  myself 
by  giving  a  saline  draught,  with  the  addition  of  fifteen  or  twenty 
grains  of  the  carbonate  of  potash,  or  the  carbonate  of  soda, 
three  or  four  times  in  the  course  of  the  day ;  but  it  soon  became 
apparent  that  in  order  to  obtain  the  full  benefit  of  alkalies,  it 
is  necessary  to  give  them  in  very  much  larger  quantities — in 
doses  proportioned  to  the  extreme  acidity  of  the  system.'     In 

>  Though  I  speak  throughout  of  the  administration  of  alkalies,  I  include 
under  this  term  the  neutral  salts,  such  as  the  potassio  tartrate  of  soda  and  the 


OR    RHEUMATIC   FEVER.  115 

ordinary  doses  they  generally  mitigated  the  severity  of  the  pain, 
yet  failed  in  aifording  more  than  partial  relief,  while  in  the 
more  important  matter  of  protecting  the  heart  from  mischief 
they  often  proved  inefficacious.  Indeed,  it  was  obvious  that 
until  the  urine  and  saliva  become  alkaline,  and  thus  give  evi- 
dence of  the  full  effect  of  the  alkalies  on  the  system,  the  heart 
remains  exposed  to  the  danger  of  inflammation.  My  endeavor, 
therefore,  has  ever  been  to  produce  this  altered  condition  of 
the  secretions  as  speedily  as  possible,  and  with  this  view  I  have 
administered  alkalies  in  large  doses,  repeated  at  short  intervals. 
Nor  have  I  seen  reason,  on  any  one  occasion,  to  hesitate  in 
following  out  this  plan  of  treatment.  It  has  now  been  pursued 
in  a  large  number  of  cases,  and  in  almost  every  instance  has 
produced  the  most  astonishingly  favorable  results.  The  patients 
have  speedily  lost  their  pains,  and  have  proceeded  rapidly  to  con- 
valescence. In  one  hundred  and  six  out  of  one  hundred  and  sixty- 
eight  cases  in  my  note-book,  the  pulse  was  tranquilized  within 
forty-eight  hours  from  the  commencement  of  treatment,  and  in 
one  hundred  and  ten  the  pain  was  lulled,  and  the  local  inflam- 
mation greatly  subdued  within  the  same  time,  while  in  most  of 
the  remaining  cases  a  longer  period  was  required,  in  conse- 
quence either  of  previous  constipation,  or  <of  the  coexistence 
of  some  internal  complication.  Moreover,  among  the  last 
hundred  and  twenty-six  cases  in  which  the  heart  remained  free 
from  inflammation  at  the  time  the  patients  were  first  brought 
under  my  care,  not  a  single  instance  of  pericarditis  or  endocar- 
ditis has  occurred,  the  heart  having  been  protected  by  the  ad- 
ministration of  the  remedies  in  the  manner  already  pointed  out. 
The  form  in  which  I  usually  prescribe  the  remedies,  is  that 
of  an  effervescing  citrate  of  potash  or  ammonia  draught  with 
an  excess  of  from  forty  to  sixty  grains  of  the  bicarbonate  of 
potash,  or  bicarbonate  of  soda,  to  which,  if  the  patient  be  a 
person  of  average  strength  and  robustness,  bathed  in  profuse 

acetate  of  potash,  which,  as  pointed  out  by  M.  Wuhler,  very  readily  undergo 
oxidation  in  the  system,  and  being  converted  into  carbonates  or  bicarbonates, 
react  on  the  secretions  as  alkalies.  In  large  doses  they  are  much  more  readily 
tolerated  by  the  stomach  than  corresponding  quantities  of  the  alkaline  carbo- 
nates. 


116  TREATMENT    OF   ACUTE   RHEUMATISM, 

perspiration,  -with  red,  swollen,  and  exquisitely  painful  joints, 
a  furred  tongue,  loaded  acid  urine,  and  a  full  and  bounding 
pulse,  I  usually  add  a  drachm  or  more  of  the  acetate  of  potash,^ 
and  ten  or  fifteen  minims  of  the  vinum  colchici,  or,  if  the 
bowels  are  costive,  I  give  one  or  two  drachms  of  the  potassio 
tartrate  of  soda  instead  of  the  acetate  of  potash,  taking  care 
to  regulate  the  purgative  action  of  the  salt  by  the  administra- 
tion of  a  few  minims  of  the  tinctura  opii,  or  of  Battley's  seda- 
tive solution.  This  draught  is  repeated,  for  the  first  twelve  or 
twenty-four  hours,  at  intervals  of  two,  three,  or  four  hours, 
according  to  the  strength  of  the  patient  and  the  severity  of  the 
attack. 

Sometimes,  more  especially  if  the  lungs  are  implicated,  from 
fifteen  to  tAventy  minims  of  the  vinum  antimonii  are  added,  and 
if  the  pain  is  excessive,  I  prescribe  a  pill  containing  from  half 
a  grain  to  a  grain,  or  a  grain  and  a  half  of  opium,  or  an  equiv- 
alent dose  of  Dover's  powder  to  be  taken  once  or  twice  a  day, 
taking  care  to  increase  or  diminish  the  quantity  of  the  sedative, 
according  to  the  circumstances  of  the  case ;  on  the  one  hand 
avoiding  constipation  and  narcotism,  and  on  the  other,  guard- 
ing against  diarrhoea. 

Formerly,  I  used  to  administer  the  remedies  in  a  simple  saline 
or  niter  draught,  and  prescribed  an  efi"ervescing  draught  only 
when  the  stomach  did  not  easily  tolerate  large  doses  of  alkalies, 

1  The  virtue  of  alkalies  and  their  salts  in  rheumatism  depends,  I  believe, 
upon  their  power — 

1st.  Of  acting  as  restorers  of  the  alkaline  condition  of  the  system. 

2dly.  Of  assisting  to  maintain  the  solubility  of  the  fibrin,  and  thereby  pre- 
venting its  deposition  on  the  valvular  apparatus  of  the  heart. 

3dly.  Of  acting  most  powerfully  as  sedatives,  and  calming  the  action  of  the 
heart  and  arteries. 

4thly.  Of  increasing  the  metamorphosis  of  tissue,  and  proving  active  pro- 
vocatives of  an  increased  secretion  of  urine,  whereby  the  elimination  of  the 
materjes  morbi  is  assisted. 

Whatever  their  mode  of  action,  however,  their  effect  in  restoring  the  alkalinity 
of  the  system,  and  of  allaying  the  fever  and  subduing  the  pain  and  inflamma- 
tion, which  accompany,  if  they  be  not  consequent  upon,  the  opposite  condition, 
is  very  remarkable,  as  is  also  their  influence  in  calming  the  action  of  the 
heart  and  arteries,  and  in  causing  an  increased  flow  of  urine  and  a  vast  aug- 
mentation in  its  solid  constituents.  These  facts  receive  very  striking  illustra- 
tion in  the  cases  reported  at  the  end  of  this  Chapter. 


OR    RHEUMATIC   FEVER,  117 

or  of  the  neutral  salts.  But  the  addition  of  lemon-juice  and 
an  alkaline  carbonate  forming  a  saline  effervescing  drink, 
deprives  the  medicine  of  so  much  of  its  nauseous  quality,  and 
renders  it  so  much  less  liable  to  derange  the  stomach,  that  I 
now  make  a  practice  of  ordering  each  draught  to  be  taken  in  a 
state  of  effervescence.  And  with  this  precaution,  an  instance 
rarely  occurs  in  which  any  nausea  or  discomfort  is  produced. 
When  once  the  medicine  has  begun  to  take  effect,  which  is 
evidenced  by  the  gradual  decrease  of  the  pain,  the  tranquili- 
zation  of  the  pulse,  the  alkalinity  of  the  urine,  and  the  increase 
in  its  quantity  and  density,  the  remedies  are  repeated  every 
fourth  hour  only,  and  then  every  fifth  or  sixth  hour ;  and  usu- 
ally at  the  expiration  of  two  or  three  days,  I  find  their  work  in 
great  measure  accomplished.  Sometimes,  indeed,  before  the 
expiration  of  twenty-four  hours,  the  saliva  has  lost  its  acidity, 
the  inflammation  has  subsided,  the  pain  is  much  subdued ;  the 
pulse  has  fallen,  probably,  from  120  to  85  or  90  beats  in 
a  minute ;  the  tongue  has  become  moister  and  less  red  and 
furred  ;  the  urine  more  abundant,  of  a  higher  specific  gravity, 
often  clear,  and  sometimes  even  alkaline,  and  the  perspiration 
less  acid,  less  sour  smelling,  and  less  profuse.  In  proportion' 
as  these  symptoms  of  amendment  manifest  themselves,  so  is  the 
dose  of  the  alkalies  decreased,  until,  after  the  lapse  of  three  or 
four  days,  I  usually  feel  justified  in  commencing  the  adminis- 
tration of  quinia  or  bark,  in  combination  with  small  doses  of 
bicarbonate  of  potash,  taking  care  to  maintain  a  free  action  of 
the  bowels,  by  exhibiting,  now  and  then  at  bedtime,  two  or 
three  grains  of  the  acetous  extract  of  colchicum,  together  with 
aloes  or  rhubarb,  and,  if  necessary,  a  grain  of  calomel  or  blue 
pill.  Should  there  be  any  acceleration  of  the  pulse,  the 
slightest  return  of  pain,  the  least  increase  of  coating  on  the 
tongue,  the  least  loading  of  the  urine,  or,  indeed,  any  evidence 
of  returning  fever,  the  use  of  the  tonic  is  at  once  abandoned 
and  alkalies  are  again  resorted  to.  But  generally  the  case 
proceeds  steadily  to  convalescence,  and  after  a  few  days  the 
pills  are  either  omitted  altogether,  or  repeated  less  frequently 
and  in  diminished  quantities.     Sometimes,  if  there  be  not  much 


118  TREATMENT    OF   ACUTE    RHEUMATISM, 

tendency  to  perspiration,  the  mistura  guaiaci  of  the  Pharmaco- 
poeia may  be  administered  with  the  addition  of  a  drachm  of  the 
volatile  tincture  of  guaiacum,  and  thirty  or  forty  minims  of 
liquor  potassse,  or  as  many  grains  of  bicarbonate  of  potash, 
while  if  the  patient  appears  to  be  cachectic,  the  decoction  of 
cinchona,  with  the  addition  of  the  ammoniated  tincture  of 
guaiacum,  or  half  a  drachm  of  the  extract  of  sarsaparilla  with 
three  or  four  grains  of  iodide  of  potassium,  and  twenty  or 
thirty  grains  of  bicarbonate  of  potash  proves  a  more  active  and 
efficient  agent. 

But  I  do  not  conj&ne  myself  to  internal  remedies.  I  en- 
deavor to  alleviate  articular  inflammation  by  means  of  external 
topical  applications. 

By  many  persons  this  practice  is  regarded  as  useless,  and  by 
some  has  been  condemned,  on  the  ground  that,  by  interfering 
with  the  inflammatory  action  taking  place  at  an  aff'ected  rheu- 
matic joint,  we  incur  the  risk  of  disturbing  the  attraction  of  the 
morbid  element,  and  of  driving  it  to  some  internal  viscus. 
Doubtless,  if  cold  topical  applications  were  to  be  employed,  and 
the  elimination  of  the  poison  thus  forcibly  arrested,  a  very  haz- 
ardous experiment  would  be  tried,  and  serious  internal  mischief 
would  probably  arise.  But  against  leeches,  blisters,  and  warm 
fomentations,  this  objection  cannot  be  reasonably  urged  :  they 
do  7iot  check  the  continuance  of  perspiration;  they  favor  rather 
than  arrest  the  exit  of  the  morbid  matter,  and  the  only  fact, 
therefore,  to  be  ascertained  in  regard  to  them,  is  their  remedial 
or  curative  power. 

It  has  been  already  stated,  that  rheumatic  inflammation  very 
rarely  leads  to  disorganization  of  the  joints,  and  moi%over  dis- 
plays a  remarkable  disposition  to  shift  or  migrate  from  one 
spot  to  another.  Hence  leeches  and  blisters  are  rarely  called 
for  in  the  acute  disease;  they  are  generally  unnecessary  for  tlie 
relief  of  the  inflammation,  and  are  useless  in  most  cases  because 
of  its  repeated  migration.  They  might,  and  indeed  they  do, 
afi'ord  very  marked  relief  to  the  severity  of  the  inflammation, 
but  they  afibrd  no  guarantee  against  its  recurrence.  Their  use, 
therefore,  should  be  restricted  to  cases  in  which  inflammation 


OR    RHEUMATIC   FEVER.  119 

lingers  about  a  particular  joint,  or  in  wliich  the  intensity  of 
the  action  is  so  great  as  to  threaten  the  integrity  of  the  struc- 
tures. But  warm  fomentations  of  every  description  may  be 
always  employed  advantageously.  They  soothe  the  parts, 
promote  perspiration,  and  thereby  favor  the  elimination  of  the 
poison.  As  the  object  of  the  applications  is  to  allay  the  pain, 
and  counteract  the  extreme  acidity  which  always  accompanies, 
if  it  be  not  the  cause  of,  rheumatic  inflammation,  it  is  manifest, 
theoretically  at  least,  that  an  alkaline  and  opiate  solution 
should  prove  the  most  eifective  remedy.  And  so  in  practice  it 
is  found  to  be.  I  have  tried  hot  water ;  I  have  tried  a  warm 
solution  of  nitrate  of  potash,  as  recommended  by  Dr.  Basham  ; 
I  have  tried  a  simple  alkaline  solution;  and  I  have  tried  a 
mixed  alkaline  and  opiate  solution,  and  the  latter  has  proved 
the  most  powerful  in  allaying  the  pain  of  rheumatic  inflamma- 
tion.' In  every  instance  in  which  it  has  been  employed,  the 
relief  obtained  has  been  almost  immediate,  and  the  pain  and 
inflammation  have  subsided  rapidly-. 

That  the  efi"ect  observed  to  follow  these  saline  fomentations 
has  not  been  due  to  accidental  causes,  is  manifest  from  the 
result  of  careful  experiment ;  for  in  twenty-two  instances  in 
which  corresponding  joints  were  afiected,  a  fomentation  of  warm 
water  was  applied  to  the  one  joint,  and  an  alkaline  and  opiate 
solution  to  the  other,  and  almost  uniformly  the  pain  and 
inflammation  continued  in  the  former,  and  speedily  subsided 
in  the  latter.  Besides  this,  I  have  endeavored  to  ascertaia 
whether  the  occurrence  of  inflammation  may  not  be  prevented 
by  impregnating  the  parts  with  alkaline  matter.^  In  thirteen 
cases  in^which  the  knees,  and  in  twelve  cases  in  which  the 
hands  were  in  the  first  instance  unafi"ected,  a  mixed  alkaline 

*  The  solution  I  usually'  employ  is  Potassae  Carb.  or  Sodae  Garb.  5iv  to  5'^j, 
Liq.  Opii  sedativi,  jj,  Glyceriiii,  ^ij,  Aqiue  Roste,  ^ix.  Sometimes,  however, 
Decoction  of  Po|)pies  is  substituted  for  ihe  Liquor  Opii  and  Rose  Water. 
Tliin  flannel  soaked  in  one  of  these  mixtures  should  be  applied  to  the  inflamed 
pnrts,  and  the  whole  should  then  be  wrapped  up  in  flannel.  In  all  cases,  how- 
ever, to  prove  effective,  the  flannel  must  be  kept  sopping  tcet,  not  merely  moist. 

*  In  a  practical  point  of  view,  the  determination  of  this  question  is  not  of 
much  importance;  but  on  theoretical  groimds,  as  bearing  upon  the  occurrence 
and  possible  prevention  of  cardiac  inflammation,  it  is  of  the  utmost  moment. 


120  TREATMENT    OF    ACUTE    RHEUMATISM, 

and  opiate  solution  was  applied  to  one  joint,  and  a  simple  water 
fomentation  to  the  corresponding  joint  on  the  other  side.  In 
five  of  the  former  cases,  and  in  three  of  the  latter,  the  joint  to 
which  water  only  had  been  applied  became  inflamed,  while  in 
one  instance  only  did  inflammation  occur,  and  that  to  a  very 
slight  extent,  in  the  joint  which  had  been  bathed  in  an  alkaline 
and  opiate  solution.^  So  that  my  experiments,  though  not  as 
yet  sufiiciently  extensive  to  enable  me  to  speak  decisively  on 
the  subject,  have,  as  far  as  they  have  gone,  proved  extremely 
satisfactory. 

One  point  yet  remains  to  be  noticed.  While  attacking  the 
disease  both  by  internal  and  external  means,  it  is  essential  to 
pay  strict  attention  to  the  diet.  The  patient  must  be  kept  low ; 
yet,  as  there  is  an  excessive  drain  upon  the  system,  it  is  expe- 
dient to  allow  him  more  nourishment  than  would  be  safe  or 
proper  in  other  inflammatory  complaints.  Strong  beef  tea  and 
jelly  may  be  given  in  moderate  quantities ;  and  with  the  view 
of  supplying  the  waste  caused  by  the  perspiration,  and  of  pro- 
moting the  dilution  and  more  rapid  absorption  of  the  alkaline 
medicines  administered  internally,  diluents,  such  as  whey,  thin 
gruel,  or  barley-water,  should  be  taken  from  time  to  time,  and 
especially  after  each  dose  of  the  medicine. 

The  folloAving  cases,  which  are  placed  in  chronological  order, 
will  serve  to  illustrate  my  plan  of  treatment. 


Case  I.^ — William  Connor,  a  carpenter,  set.  31,  was  admitted 
a  patient  of  the  Pimlico  Dispensary  on  the  16th  of  June,  1846. 
He  had  already  undergone  two  attacks  of  acute  rheumatism  ; 
the  first  ran  on  in  spite  of  treatment  for  a  period  of  seven  weeks ; 
and  the  last,  which  occurred  four  years  ago,  after  continuing  in 
an  acute  stage  nearly  five  weeks,  was  protracted  in  a  subacute 

1  I  am  indebted  to  the  kindness  of  my  colleagues,  Dr.  Wilson  and  Dr.  Bence 
Jones,  for  several  opportunities  of  trying  these  experiments. 

2  For  the  opportunity  of  seeing  and  treating  this  case,  I  am  indebted  to  my 
friend  Dr.  Blackall,  Senior  Physician  to  the  Dreadnought  Hospital  Ship,  and 
formerly  Physician  to  the  Pimlico  Dispensary. 


I 


OR    RHEUMATIC    FEVER.  121 

form  for  a  period  of  four  months.  The  present  attack  com- 
menced on  the  12th  instant,  and  was  ushered  in  by  chillin'ess, 
followed,  in  the  course  of  a  few  hours,  by  pain,  heat,  redness, 
and  swelling  of  both  wrists,  the  right  elbow,  and  his  left  knee. 
The  inflammation  shifted  rapidly  from  joint  to  joint,  and  when 
I  first  saw  him  on  the  16th,  his  right  ankle  and  both  his  elbows 
were  severely  affected.  The  pain  was  so  excessive  that  he  had 
been  unable  to  sleep  since  the  commencement  of  his  attack.  He 
was  sweating  profusely,  the  perspiration  having  the  sour  odor  of 
rheumatism,  and  standing  in  large  drops  upon  his  forehead. 
Conjunctivae  yellow ;  tongue  red  at  the  tip  and  edges,  and 
coated  in  the  center  with  a  thick  yellowish-white  fur.  Bowels 
reported  open ;  urine  scanty,  dark  colored,  and  loaded  with 
lithates ;  sp.  gr.  1025.  Saliva  extremely  acid.  Pulse  116, 
full,  and  bounding.  Heart's  action  regular,  but  its  impulse 
somewhat  increased ;  a  loud  systolic  mitral  murmur,  probably 
of  old  standing,  distinctly  heard  at  the  apex.  No  friction 
sound,  and  no  praecordial  pain. 

I  ordered  the  joints  to  be  fomented  with  the  opiate  and  alka- 
line lotion  ;  restricted  his  diet  to  beef  tea,  milk,  and  gruel,  and 
prescribed  the  following  medicine  : 

^..     Hydrargyri  Chloridi,  gr.  v;  Opii,  gr.  ij.     M.  ft.  Pilulae  duse  honl  somni 
sumendae.  * 

Haust.  SennsB  c.  Soda;  Potassio-Tart.,  3i^i  eras  primo  mane  sumendus. 
Liquoris  Potassa?,  tt^xI  ; 
Potassse  Tartratis,  5ij ! 
Vini  Colchici,  v\x; 
Tincluraj  Opii,  Tilxij  ; 

Haust.  Potasste   Citratis,  §jss.     M.  ft.  Haust.  4'*  quaque    horfi, 
sumendus. 

11th. — Passed  a  tranquil  night,  though  without  much  sleep, 
and  feels  in  every  respect  more  comfortable  to-day.  Joints 
somewhat  less  swollen  and  painful.  Tongue  moist,  but  coated. 
Saliva  still  acid.  Bowels  have  been  moved  once.  Urine  more 
plentiful,  (reported  about  1|  pints,)  less  loaded ;  sp.  gr.  1028. 
Pulse  96.     Heart's  sounds  the  same  as  yesterday. 

To  continue  the  draught  and  fomentations  as  before. 
To  take  two  grains  of  Opium  at  bedtime. 
9 


122  TREATMENT    OF   ACUTE    RHEUMATISM, 

18th. — Passed  a  quiet  night,  and  slept  nearly  five  hours. 

Joints  still  slightly  swollen,  but  scarcely  at  all  painful.     Still 

perspires  freely.     Conjunctivae  yellowish.     Tongue  moist  and 

cleaning  rapidly.      Saliva  faintly  acid.     Bowels  have  not  been 

relieved.     Urine    about  3|^  j)ints,  clear,  acid ;    sp.  gr.  1026. 

Pulse  80,  soft.     Heart's  action  regular,  and  sounds  just  as  on 

admission. 

To  repeat  the  medicine  every  six  hours. 
To  take  the  pills  and  Senna  draught,  as  ordered  on  the  16th. 

19th. — Slept  well,  and  is  rapidly  improving  in  every  respect. 
There  have  been  two  full  evacuations  from  the  bowels;  the  tongue 
continues  to  clean,  and  is  no  longer  red ;  and  the  urine  is  re- 
ported about  the  same  as  yesterday  ;  none  has  been  saved  for 
examination.     Pulse  76,  rather  weak. 

To  repeat  the  medicine  twice  a  day.  and  to  take  a  grain  of  Opium  at 
bedtime. 

20th. — Slept  soundly  last  night,  and  to-day  is  free  from  pain 
and  swelling  of  the  joints,  slight  stiffness  and  uneasiness  alone 
remaining  about  the  right  wrist.  Tongue  quite  clean  and  moist. 
Bowels  somewhat  costive.  Urine  very  abundant,  clear,  and  acid ; 
sp.  gr.  1027.  Pulse  64,  and  somewhat  weak.  Is  up  and  dressed 
to-day,  but  feels  very  low. 

To  omit  the  saline  medicine,  and  take  the  following : 
J^.     Quinae  Disulphatis,  gr.  ij ; 
Sulphatis  Magnesiae,  5ss ; 
Acidi  Sulphurici  dil.,  ff^v  ; 
Tincture  Aurantii,  3ss ; 

Aquae  destillata.  3JSS.     Ft.  haustus  bis  die  sumendus. 
Haustus  Senna;  c.  Soda?  Pota?sio-Tart..  '^'iv,  eras  mane. 
Fish  and  beef  tea. 

From  this  time  he  proceeded  steadily  to  convalescence ;  and 
on  the  24th  was  so  far  improved  that  he  asked  leave  to  be 
allowed  to  resume  work.  He  was  induced,  however,  to  take 
the  Quinia  for  a  few  days  longer  ;  but  on  the  26th  he  felt  so 
thoroughly  well  that  he  betook  himself  to  his  ordinary  occupa- 
tion. 


OR   RHEUMATIC    FEVER.  123 

Case  II. — William  Made,  a  thin,  pale,  unhealthy-looking 
boy,  set.  15,  was  received  as  a  patient  under  my  care  at  St. 
George's  Hospital,  on  the  24th  of  August,  1850.  He  had  got 
wet  through  on  the  morning  of  the  21st,  and  in  the  evening  of 
the  same  day  had  been  attacked  with  shivering,  succeeded  by 
wandering  pains  in  the  limbs.  In  the  course  of  a  few  hours 
the  pain  seized  upon  the  joints,  and  the  right  hand  and  wrist, 
the  left  knee  and  both  ankles  became  inflamed  and  swollen. 
The  inflammation,  however,  had  shifted  rapidly  from  joint  to 
joint ;  and  when  I  first  saw  him,  his  left  hand  and  wrist,  the 
right  knee  and  elbow,  and  his  left  ankle  were  the  inflamed 
parts.  He  had  been  unable  to  sleep  since  the  beginning  of  the 
attack,  his  complexion  was  sallow,  the  countenance  distressed, 
and  he  was  sweating  profusely.  Tongue  white  and  furred. 
Bowels  costive.  Urine  scanty,  high  colored,  and  loaded  with 
lithates  ;  sp.  gr.  1020.  Pulse  126,  full  and  bounding,  but  not 
strong.  Heart's  action  regular,  the  sounds  distinct  and  free 
from  murmur.  Saliva  strongly  acid.  He  had  no  hereditary 
tendency  to  rheumatism,  (?)  and  the  present  was  his  first  attack. 
The  inflamed  joints  were  at  once  wrapped  up  in  flannels, 
soaked  in  a  lotion  formed  by  dissolving  an  ounce  of  the  carbo- 
nate of  potash  in  a  pint  of  decoction  of  poppies ;  his  diet  was 
limited  to  beef  tea,  gruel,  and  arrow-root ;  and  the  following 
medicines  were  prescribed : 

I^.     Hydrargyri  Chloridi, 

Pulveris  Doveri,  aa,  gr.  iij.     M.  ft.  Pulvis  statim  sumendus. 
Haustus  Seunie  c.  Sodae  Potassio-Tart.,  3''J!  P^st  boras  quinquo. 

Haustiis  Salini,  §j<s ; 

Soda;  Potassio-Tartratis,  3'j ; 

Vini  Colchici,  Tt^xv ; 

Tincturae  Opii,  fH.^'U-     M-  ft-  Haust.  G*"  quaque  hora  sumendus. 

August  25th. — Passed  a  tranquil  night,  though  without  much 
sleep,  and  to-day  is  comparatively  easy.  The  redness  has 
almost  disappeared,  and  the  swelling  has  subsided  considerably. 
Bowels  acted  on  twice  by  the  medicine  yesterday,  and  to-day 
have  been  freely  moved  once.  Perspiration  still  very  profuse 
and  acid.  Urine  about  1^  pints,  besides  what  was  passed  at 
stool;    acid;    less   high    colored    and    loaded;    sp.   gr.   1031. 


124         TREATMENT  OF  ACUTE  RHEUMATISM, 

Tongue  moist  and  much  cleaner.     Pulse  98,  soft.     Heart's 
sounds  clear.     Saliva  still  acid. 

Rep.  Haustus  C'*  qu&que  hora. 
^.     Pulv.  Ipecac,  comp.,  gr.  x; 

Hydrarg.  Chloridi,  gr.  iij.     M.  ft.  Pulvis  hac  nocte  sumendus. 

26^7?. — Slept  well  last  night ;  to-day  has  neither  redness  nor 
swelling  of  the  joints,  and  slight  stifiFness  only  remains.  Still 
perspiring  freely.  Bowels  have  acted  once.  Tongue  moist, 
and  cleaning  rapidly.  Urine  reported  about  2|  pints,  clear 
and  acid ;  sp.  gr.  1030.  Pulse  86,  soft.  No  exocardial  or 
endocardial  murmur.     Saliva  neutral. 

Rep.  Haustus  ter  die  tantum. 

27<A. — Passed  another  quiet  night,  and  has  no  return  of  pain. 
Bowels  have  acted  once.  Tongue  quite  clean,  except  just  in 
the  center,  where  it  is  rather  white.  Urine  clear,  and  in  great 
abundance ;  sp.  gr.  1030.  Pulse  76,  soft.  Is  up  and  about 
to-day. 

^.     Haustus  Quinse  c.  Acid.  Sulph.  dil.,  Ti\xv,  Sulph.  Magnesise,  5ss,  bis 
die. 

From  this  time  he  continued  taking  the  quinia  until  the  30th, 
when,  having  had  no  return  of  pain,  and  feeling  quite  well,  the 
medicine  was  discontinued. 


Case  III. — Samuel  Bates,  a  porter,  set.  86,  was  admitted 
into  the  King's  Ward  of  St.  George's  Hospital,  on  the  9th  of 
September,  1850.  His  father  was  a  martyr  to  rheumatism, 
and  he  himself,  about  seven  years  ago,  underwent  an  acute 
attack  of  the  disease,  which  confined  him  to  bed  above  two 
months.  Nine  months  ago  he  suffered  from  lumbago  during 
the  space  of  three  weeks,  but  on  no  other  occasion  had  he  ex- 
perienced any  symptom  of  rheumatism  since  his  former  illness. 
The  present  attack,  which  commenced  on  the  4th  instant,  was 
preceded  for  a  week  by  loss  of  appetite,  languor,  and  inability 
to  apply  himself  to  work.  Shivering,  followed  by  fever,  super- 
vened ;  and,  in  the  course  of  twenty-four  hours,  several  of  his 


OR    RHEUMATIC   FEVER.  125 

joints  became  red,  swollen,  and  exquisitely  painful.  Since  that 
time,  the  pain  and  swelling  have  shifted  repeatedly  from  limb 
to  limb,  and  he  has  had  scarcely  an  hour's  sleep. 

On  admission,  the  left  knee,  the  right  foot  and  ankle,  and 
the  left  wrist  and  elbow  were  inflamed  and  swollen ;  there  was 
profuse  perspiration  of  a  peculiarly  strong  empyreumatic 
odor,  and  he  complained  greatly  of  thirst.  The  heart's  action 
was  regular,  and  the  sounds  were  clear.  Tongue  furred,  and 
red  at  the  tip  and  edges.  Saliva  acid.  Bowels  reported  open. 
Urine  scanty,  and  loaded  with  lithates ;  sp.  gr.  1023.  Pulse 
126,  full  and  strong. 

The  inflamed  joints  were  fomented  with  an  alkaline  and 
opiate  solution,  and  the  following  medicines  were  ordered : 

IJ.     Hydrargyri  Chloridi,  gr.  iv ; 
Ext.  Aloes  Aquosi,  gr.  iij ; 
Extract!  Colchici  Acet.,  gr.  jss  ; 
Opii,  gr.  ij.     M.  ft.  Pilulae  duae  statim  sumendae. 

Sodae  Potassio-Tartratis,  ijss ; 
Vini  Colchici,  iHxij ; 
Tincturae  Opii,  v\x; 

Haustus  Potassae  Citratis,  §jss.     M.  ft.  Haustus  tertia  quaque  hor& 
sumendus. 
Pulv.  Ipecacuanhoe,  gr.  xv,  hora  somni. 
Barley-water  as  a  drink,  beef  tea  and  arrow-root. 

September  10th. — Passed  a  quiet  but  sleepless  night.  Joints 
still  inflamed,  though  less  so  than  yesterday.  Perspiration 
continues.  Heart  sounds  clear  and  action  regular.  Pulse  110. 
Bowels  acted  last  night,  but  have  not  done  so  to-day.  Tongue 
less  red.  Saliva  still  acid.  Urine  in  larger  quantity  (IJ 
pints)  loaded  with  lithates;  sp.  gr.  1023.  Revolts  at  the 
medicine,  which  causes  excessive  nausea,  but  has  not  given  rise 
to  vomiting. 

Rep.  Pulveris  Doverl,  gr.  xv,  hora  somni. 
^..     Potassae  Bicarbonatis,  5j ; 

Sodae  Potassio-Tartratis,  5jss ; 
Vini  Colchici,  Tt^x ; 
Tincturffi  Opii,  "Hl^i'j  i 

Haustus  Potasste  Citratis,  ^jss.   M.  ft.  Haustus  c.   Acid.  Citrici,  3ji, 
tertia  quaque  hora  sumendus. 
Haustus  Sennae  c.  Sod^  Potassio-Tartratis,  3'^;  eras  mane. 


126         TREATMENT  OF  ACUTE  RHEUMATISM, 

11th. — Slept  four  or  five  hours  last  night,  and  feels  easier  in 

every  respect  to-day.       Still  perspires  profusely.       No  joint 

swollen  except  the  knee,  and  that  only  slightly  so,  but  the 

■whole  body  feels  very  stiff.      Heart  unaffected.      Pulse  84, 

soft.    Tongue  much  cleaner  and  less  red,  saliva  neutral.    Bowels 

have  acted  freely  twn'ce,   urine  clear,  plentiful,  (about  three 

pints,)  slightly  acid;  sp.  gr.  1028.     Medicine  no  longer  gives 

rise  to  nausea. 

Repet.  Pulvis  Doveri  hora  somni. 
Repet.  Haustus,  4^  quaque  hora. 

12th. — Slept  soundly  last  night,  and  has  no  longer  any 
swelling  or  inflammation  of  the  joints.  His  only  complaint  is 
of  stiffness.  No  endocardial  or  exocardial  murmur.  Pulse  80, 
soft.  Tongue  moist  and  almost  clean.  Saliva  alkaline.  Bowels 
not  open.  Urine  very  abundant,  a  chamber-pot  full;  sp.  gr. 
1029.  Slightly  alkaline  from  fixed  alkali.  Skin  still  per- 
spiring, but  not  profusely  as  before. 

^.     Ext.  Colchici  Acet., 
Hydrargyri  Chloridi, 
Ext.  Aloes  Aquosi,  aa  gr.  ij ; 

Opii,  gr.  ss.     M.  ft.  Pilulae  duraj  hora  somni  sumendae. 
Repetatur  haustus  ter  die  tantum. 

liith. — Passed  a  quiet  night  and  slept  soundly.  No  longer 
perspires.  No  return  of  pain  or  swelling.  Complains  of  being 
hungry,  and  wishes  to  get  up.  Tongue  clean.  Bowels  freely 
open.  Urine  clear,  abundant,  slightly  alkaline  from  fixed 
alkali;  sp.  gr.  1030. 

Repetatur  haustus  bis  die  tantum. 
Fish  diet. 

14:th. — Is  up  and  dressed  to-day.  His  only  complaint  is  of 
stiffness  of  the  shoulders  and  general  weakness.  Tongue  clean. 
Bowels  open.     Urine  slightly  acid. 

11  th. — Quite  well,  but  weak.    Tongue  clean.    Bowels  regular. 

Omittatur  haustus  saliuus. 
J^.     Haustus  Quinse,  bis  die. 
Ordinary  diet,  without  beer. 

From  this  time  he  progressed  favorably.     On  the  24th,  after 
walking  in  the  garden  he  had  slight  stiffness  about  the  shoul- 


i 


OR    RHEUMATIC    FEVER.  127 

ders,  which  was  at  once  relieved  by  a  vapor  bath,  and  with 
this  exception  he  experienced  no  drawback — and  he  remained 
so  free  from  pain  that  it  was  judged  safe  to  let  him  leave  the 
hospital  on  the  2d  of  October. 


Case  IV. — Frank  Hatcher,  set.  16,  was  admitted  into  the 
York  Ward  of  St.  George's  Hospital,  on  the  27th  of  February, 
1856.  He  had  been  seized  on  the  23d  instant,  with  violent 
rigors,  followed  by  wandering  pains  in  the  limbs,  pain,  swell- 
ing, and  redness  of  the  joints,  and  excessive  feverishness.  The 
pains  had  shifted  rapidly  from  joint  to  joint,  so  that  during 
the  four  days  which  had  elapsed  since  his  seizure,  almost  all 
the  joints  had  been  severely  visited.  He  had  been  unable  to 
sleep  throughout,  and  had  been  constantly  bathed  in  profuse, 
sour-smelling  perspiration. 

When  I  first  saw  him  after  admission,  his  knees,  ankles,  and 
the  left  wrist  and  elbow  were  inflamed,  swollen,  and  extremely 
painful;  he  was  sweating  profusely,  the  perspiration  having 
the  peculiar  acid  odor  of  rheumatism.  The  pulse  was  124, 
full,  but  not  hard.  Tongue  furred  and  red.  Saliva  acid. 
Urine  very  scanty,  high  colored,  and  loaded  with  lithates ;  sp. 
gr.  1022.  Bowels  costive.  Conjunctivae  yellow.  He  had 
much  thirst,  and  total  loss  of  appetite.  Heart's  action  regular, 
and  its  sounds  clear.  He  had  no  hereditary  tendency  to 
rheumatism,  nor  had  he  experienced  a  previous  attack. 

Beef  tea  and  gruel  were  ordered  as  food ;  barley-water  was 
given  as  a  beverage.  The  joints  were  fomented  as  usual;  and 
the  following  medicines  were  prescribed : 

^.     Hydrarg.  Chloridi,  gr.  v ;   Ext.   Colchici  Acet.,  gr.   iij ;   Opii,  gr.   ss. 
M.  ft.  Pilulie  dua;  statim  sumendoe. 
Haust.  SennaB  c.  Sodto  Potassio-Tart.,  5'j;  P^st  horas  quatuor. 
Potassse  Bicarbonatis,  5J ; 
Sodte  Potassio-Tartratis,  5jss ; 
Vini  Colchici,  T^x ; 
Tincturse  Opii,  Hlviij ; 

Haust.  PotassEe  Citratis,  §jss.  M.  ft.  Haustus  4'*  quaque  bora  sumen- 
dus  c.  Acidi  Citrici,  3j. 


128         TREATMENT  OF  ACUTE  RHEUMATISM, 

August  2Sth. — The  bowels  acted  freely  after  the  medicine, 
but  he  has  passed  a  restless  night,  sweating  profusely,  and  the 
pains  are  still  severe,  but  the  swelling  and  redness  are  sub- 
siding. Heart  unaffected.  Pulse  104,  less  full  and  bounding. 
Tongue  much  the  same  as  yesterday.  Urine  much  more  abund- 
ant, but  still  loaded  with  lithates;  sp.gr.  1024.    Saliva  neutral. 

Repetatur  haustus  3"*  quaque  hora. 
Haust.  Morphise,  §iij,  hora  somni. 

Repetatur  haustus  Sennffi  eras  mane. 

February  29th. — Passed  a  good  night,  and  is  much  better 

to-day.     Still  perspiring  freely.     The  left  knee  only  remains 

swollen,  and  is  not  very  painful.     Heart  sounds  clear.     Pulse 

80,  soft.     Tongue  much  less  red,  and  almost  clean.     Bowels 

open,   but  not  freely.      Conjunctivae  rather  yellow.       Urine 

abundant,  2^  pints,  clear,  slightly  alkaline,  from  fixed  alkali ; 

sp.  gr.  1028.      Saliva  alkaline.     Begins  to  ask  for  more  food. 

Repetatur  haustus  4**  quaque  hora. 
Repetantur  Pilulae  nuper  prajscriptaj  hue  nocte. 

March  1st. — Has  passed  a  quiet  night,  though  without  much 
sleep.  No  swelling  remains,  and  but  little  pain.  Heart's 
action  regular;  sounds  clear.  Perspiration  continues,  and  is 
still  acid.  Bowels  have  acted  freely.  Tongue  clean  and  much 
less  red.  Urine  abundant;  still  rather  alkaline;  sp.  gr.  1028. 
Saliva  alkaline. 

Repetatur  haustus  6'*  quaque  hora. 

Zd. — No  longer  any  pain.     Complains  of  being  hungry,  and 

wishes  to  get  up  and  dress.     Tongue  clean.     Bowels  regular. 

Urine  abundant,  clear,  and  almost  neutral.     Skin  moist,  but 

not  bathed  in  perspiration  as  before. 

Repetatur  haustus. 
Fish  diet ;  to  keep  in  bed. 

5th. — Still  continues  free  from  pain.     No  longer  perspires. 

Repetatur  haustus  ter  die  tantum. 

May  get  up  and  dress  to-day. 

From  this  time  until  the  10th  the  medicine  was  continued  as 
a  precautionary  measure  three  times  a  day,  but  as  he  then 
remained  quite  free  from  pain,  all  medicine  was  discontinued, 


OR   RHEUMATIC   FEVER.  129 

and  ordinary  diet  was  prescribed.  With  the  view,  however,  of 
guarding  against  the  recurrence  of  the  disease,  he  was  kept  in 
the  hospital  until  the  19th,  when,  as  he  was  still  free  from  any 
symptom  of  rheumatism,  he  was  permitted  to  return  home. 


Case  V. — Mary  Wood,  set.  15,  was  admitted  into  Queen's 
Ward  on  the  1st  of  July,  1857.  Six  days  previously  she  had 
been  seized  with  wandering  rheumatic  pains,  followed,  in  the 
course  of  twenty-four  hours,  by  pain,  redness,  and  swelling  of 
the  knees,  ankles,  and  right  wrist.  She  had  never  before 
experienced  an  attack,  and  could  not  account  for  her  present 
seizure  ;  but  her  mother  admitted  that  she  had  been  "  off  her 
feed"  during  the  previous  six  or  eight  days.  Since  the  com- 
mencement of  her  illness  she  had  been  unable  to  obtain  a 
"wink  of  sleep." 

On  admission,  her  face  was  pale,  the  skin  hot,  but  not  per- 
spiring. Tongue  furred.  Saliva  acid.  Bowels  reported  open. 
Urine  scanty,  high  colored,  acid,  and  turbid ;  sp.  gr.  1023. 
Pulse  ]  20,  full  and  bounding.  The  catamenia  had  not  appeared. 
The  heart's  sounds  were  free  from  murmur.  The  left  knee, 
both  ankles,  and  the  right  wrist  were  hot,  red,  swollen,  and 
painful. 

An  alkaline  and  opiate  fomentation  was  ordered  for  the 
joints;  and,  as  the  skin  was  not  acting  freely,  I  prescribed  a 
vapor  bath  in  the  evening.  The  following  medicines  were  also 
given  : 

^.     Extract!  Colchici  Acetici,  gr.  ij : 

Pilulae   Colocynth  c.    Calomelane,  gr.  viij.    M.  ft.  pilulae  duae  horfi, 

somni  htlc  nocte  sumendae. 
Potassae  Acetatis,  3ij ; 
Potassse  Bicarbonatis,  5j  j 
Vini  Colchici,  ir^viij. 

Haustus  Acetatis  Ammonias,  ^iss.     M.  ft.  haustus   4**  quaque  horfl, 
sumendus  c.  Acidi  Citrici,  3j. 
Beef  tea. 

2d, — The  vapor  bath  acted  well,  and  she  has  ever  since  per- 
spired freely.     No  sound  sleep,  but  dozed  at  intervals  during 


130         TREATMENT  OF  ACUTE  RHEUMATISM, 

the  night.  Pains  much  easier,  and  the  joints,  though  swollen, 
arc  no  longer  red.  Tongue  cleaner.  Bowels  have  acted  freelj. 
Urine  plentiful,  clear,  slightly  acid  ;  sp.  gr.  1026.  Pulse  108, 
soft  and  regular.     Heart's  sounds  clear. 

Sd. — Slept  better  last  night,  and  has  less  pain  than  yester- 
day. Still  perspires  profusely.  Tongue  white,  but  moist,  and 
clean  at  the  tip  and  edges.  Bowels  have  not  acted.  Urine 
abundant,  alkaline ;  sp.  gr.  1026.  Pulse  84,  soft.  Heart's 
sounds  clear. 

Repetatur  haustus  ter  die  tantum. 
Repetantur  pilulaj  hue  nocte. 

4:th. — Slept  tolerably  well  last  night.  Has  still  some  uneasi- 
ness in  the  right  knee,  but  in  no  other  part  of  the  body. 
Bowels  have  acted  freely.  Tongue  almost  clean.  Urine  still 
alkaline,  about  2|  pints ;  sp.  gr.  1026.  Pulse  72,  weak.  The 
last  dose  of  the  medicine  made  her  vomit. 

]^.     TincturiE  Guaiaci  Ammon.,  5J  ', 
Potassae  Acetatis,  33S ; 
Liquoris  Potassce,  Sss ; 

Haustus  CinchontB,  5xss.     M.  ft.  haustus  ter  die  sumendus. 
Fisii  and  beef  tea. 

From  this  time  her  progress  toward  recovery  was  steady  and 
rapid.  On  the  7th  I  deemed  it  safe  to  prescribe  meat ;  on  the 
9th  she  was  permitted  to  get  out  of  bed  and  dress ;  and  on  the 
16th,  as  she  remained  quite  free  from  pain,  she  was  allowed  to 
leave  the  hospital. 


Case  VI. — Timothy  Suter,  aet.  29,  was  admitted  into  the 
Hope  Ward  of  St.  George's  Hospital  on  the  2d  of  July,  1859. 
A  groom  by  occupation,  he  had  been  somewhat  languid,  but 
not  notably  out  of  health  until  five  days  prior  to  his  admission, 
when  he  was  seized  with  wandering  rheumatic  pains,  and  swell- 
ing of  the  larger  joints.  Feverish  symptoms  then  ensued  ;  he 
lost  his  appetite,  became  restless  and  unable  to  sleep  at  night, 
and  began  to  perspire  profusely.  The  present  was  his  first 
attack,  and  it  was  not  preceded  by  rigors. 


OR   RHEUMATIC   FEVER.  131 

I  saw  him  the  first  day  after  admission,  when  his  face  was 
flushed,  the  conjunctivae  Avcre  yellowish,  the  skin  was  hot,  and 
perspiring  profusely,  the  perspiration  emitting  a  strong  empy- 
reumatic  odor ;  tongue  coated  and  rather  dry  in  the  center, 
saliva  acid,  bowels  reported  costive,  urine  scanty,  high  colored, 
and  charged  with  lithates  ;  sp.  gr.  1021.  Pulse  110,  regular, 
full,  and  hounding.  The  wrists,  elbows,  knees,  and  ankles 
were  all  much  swollen,  red,  and  exquisitely  painful.  He  was 
complaining  of  pain  in  the  region  of  the  heart,  and  a  systolic 
aortic  murmur  was  audible  at  the  base. 

As  the  pulse  was  regular,  and  the  other  symptoms  did  not 
appear  to  indicate  active  mischief  about  the  heart,  I  merely 
ordered  the  joints  to  be  fomented  as  usual,  and  prescribed  the 
following  medicines : 

I^.     Extract!  Colchici  Acetici,  gr.  ij ; 

Pilulie  Colocynth  c.  Calomelane,  gr.  viij.     M.  ft.  pilulae  du£e  hord 

somni  hac  nocte  sumendse. 
Potassas  Bicarbonatis,  5iss; 
Sodse  Potassio-Tartratis,  3'j ; 
Vini  Colchici,  Til^x; 

Haustus  Acetatis  Ammoniaj,    §ij.     M.  ft.  haustus  4'*   quaque   hord 
sumendus  c.  Acidi  Citrici,  3j. 
Beef  tea. 

^th. — He  had  passed  a  restless  night,  but  his  joints  were  no 
longer  red,  and  were  less  swollen  and  much  less  painful.  The 
bowels  had  not  acted.  Tongue  furred,  yellowish,  and  somewhat 
dry  in  the  center.  Urine  about  a  pint  and  a  half,  sp.  gr.  1024, 
acid,  no  longer  loaded  with  lithates.  Perspiration  still  profuse. 
Pulse  96,  regular.     Heart's  sounds  as  before. 

The  mixture  was  ordered  to  be  repeated,  and  the  following 
medicines  were  also  prescribed  : 

Hydrargyri    Chloridi,    gr.    iij  ;    Opii,    gr.  j.      M.    ft.   pilula   statim 

sumenda. 
Haustus  Sennaj  c.  Sod«  Potassio-Tartratis,  "^'ix ;  post  horas  tres. 

bth. — The  bowels  acted  freely  after  the  senna,  and  he  slept 
at  intervals  throughout  the  night.  The  joints  are  far  less 
swollen  and  painful,  so  that  he  can  move  in  bed  without  assist- 
ance.    Tongue  moist  and  coated,  but  cleaning  at  the  edges. 


132  TREATMENT   OF   ACUTE   RHEUMATISM, 

Bowels  open.  Urine  still  acid,  but  clear,  more  abundant, 
about  2h  pints ;  sp.  gr.  1028.  Pulse  92,  soft  and  regular. 
Heart's  sounds  as  before,  but  murmur  less  loud. 

Repetatur  baustus  4'"  quaque  hora. 

6th. — Passed  a  fair  night,  and  has  not  much  pain  remaining. 
Still  perspires  freely.  Tongue  much  cleaner.  Bowels  rather 
relaxed.  Pulse  80,  soft  and  regular  ;  urine  clear,  but  alkaline. 
Its  amount  could  not  be  ascertained,  as  so  much  was  passed  at 
stool.     Heart's  sounds  as  before. 

Repetatur  haustus  ter  die  tantum. 

1th. — Slept  soundly,  and  feels  quite  well  to-day.     No  longer 

any  pain.     Tongue    cleaning.      Bowels   freely  open.     Urine 

abundant,  turbid,  alkaline.     Pulse  76,  weak. 

Repetatur  haustus  bis  die  tantum. 
Fish  and  beef  tea. 

9th. — No  return  of  pain.  Tongue  nearly  clean.  Urine  still 
slightly  alkaline.     Is  up  and  dressed  to-day. 

Omittatur  haustus  salinus. 
^.     Haustus  Quina?  c.  Sulph.  Magnesias,  5ss  ;  bis  die. 

lOih. — Continues  well. 

Ordinary  diet. 

A  systolic  murmur  still  remained  at  the  base  of  the  heart, 
but  it  was  very  slight,  and  soft  in  character.  In  otlier  respects 
he  was  quite  well,  and  he  was  therefore  permitted  to  leave  the 
hospital  on  the  13th  of  July. 

The  cases  above  detailed  afford  sufficient  illustration  of  the 
effects  produced  by  the  plan  of  treatment  above  laid  down. 
Its  influence  over  the  pulse  and  the  urinary  secretion  is  seen 
to  be  most  rapid  and  striking,  as  is  also  its  power  of  subduing 
the  pain  and  arresting  the  progress  of  the  inflammation. 

In  Case  I — The  pulse  fell  from  116  to  80  within  48  hours, 
and  to  76  on  the  third  day. 
"  The   urine,   from   being   scanty   and   loaded, 

became  plentiful  and  less  loaded  within  24 
hours ;  and  still  more  abundant  and  clear, 
sp.  gr.  1026,  in  48  hours. 


OR   RHEUMATIC   FEVER.  133 

In  Case  I — The  inflammation  of  the  joints  was  almost  sub- 
dued at  the  expiration  of  48  hours,  and 
subsided  altogether  by  the  fourth  day. 

In  Case  II — The  pulse  fell  from  126  to  86  in  48  hours,  and 
to  76  on  the  third  day. 
"  The   urine,    from   being    scanty    and   loaded, 

became  abundant   and   less   loaded  in   24 
hours,  and  still  more  abundant  and  clear, 
sp.  gr.  1080,  in  48  hours. 
"  The  articular  inflammation  was  greatly  relieved 

within  24'  hours,  and  subsided  altogether 
within  48  hours. 

In  Case  III— The  pulse  fell  from  126  to   110  in  24  hours, 
and  to  84  within  48  hours. 
"  The  urine,  from  being  scanty  and  loaded  with 

lithates,  became  much  more  abundant  on 
the    second  day ;    and  very  plentiful   and 
clear,  sp.  gr.  1028,  on  the  third  day. 
"  The  inflammation  of  the  joints  began  to  subside 

within  24  hours,  and  had  almost  wholly 
ceased  within  48  hours. 

In  Case  IV — The  pulse  fell  from  124  to  104  in  24  hours, 
and  to  80  in  48  hours. 
"  The  urine,  from  being  very  scanty,  high  colored, 

and   loaded  with    lithates,   sp.    gr.    1022, 
became  much  more  abundant,  sp.  gr.  1024, 
in  24  hours  ;  and  very  plentiful  and  clear, 
sp.  gr.  1028,  in  48  hours. 
"  The  pain,  redness,  and  swelling  of  the  joints 

were  much  reduced  in  24  hours,  and  were 
altogether  subdued  within  three  days. 

In  Case  Y—The  pulse  fell  from  120  to  108  in  24  hours,  and 
to  84  in  48  hours. 
"  The  urine,  from  being  scanty,  high  colored, 

and  turbid,  sp.  gr.  1023,  became  much  more 
abundant,  clear,  and  only  slightly  acid,  sp. 
gr.  1026,  in  24  hours,  and  still  more  abund- 
ant, alkaline,  sp.  gr.  1026,  in  48  hours. 


134         TREATMENT  OF  ACUTE  RHEUMATISM, 

In  Case  V — The  articular  injiammation  was  greatly  reduced 
within  24  hours,  and  subsided  altogether 
within  three  days. 

In  Case  VI — The  pulse  fell  from  110  to  96  within  24  hours, 
to  92  within  48  hours,  and  to  80  within  72 
hours. 
"  The  U7'{ne,  which  at  first  was  scanty,  charged 

with  lithates,  sp.  gr.  1021,  increased  in 
quantity,  and  became  almost  clear  within 
48  hours,  and  still  more  abundant  and  quite 
clear,  sp.  gr.  1028,  on  the  third  day ;  on 
the  fourth  day  it  became  alkaline. 
"  The  articular   inflammation  was  considerably 

reduced  by  the  end  of  the  third  day,  and 
had  subsided  altogether  by  the  end  of  the 
fourth  day. 

These  results  must  not  be  regarded  as  exceptional  in  their 
character.  The  cases  have  been  selected,  not  on  account  of 
their  favorable  issue,  but  as  average  examples  offering  good 
illustrations  of  the  acute  disease,  and  of  the  means  employed 
to  subdue  it. 

On  analyzing  168  cases  which  I  have  treated,  after  the  plan 
above  detailed,  I  find  that  31  were  accompanied  by  symptoms 
of  endocardial  or  exocardial  inflammation  ;  but  that  in  5  only 
did  such  symptoms  manifest  themselves  after  the  commence- 
ment of  treatment,  and  that  before  the  full  effect  of  the  reme- 
dies could  be  felt.  Excluding  these  31  cases,  the  pulse  in  34 
instances  fell  between  20  and  30  beats  within  thirty  hours,  and 
to  the  same  extent  within  forty-eight  hours  in  72  others ;  in  16 
it  was  not  subdued  to  such  an  extent  until  the  expiration  of 
three  days ;  in  5  not  until  the  fourth  day ;  in  2  not  until  the 
fifth  day ;  and  in  4  not  until  the  sixth  day  of  treatment.  In  4 
cases  the  precise  frequency  of  the  pulse  after  the  first  forty- 
eight  hours  was  not  noticed.  In  122  instances  it  had  fallen 
below  92  before  the  expiration  of  the  third  day  of  treatment. 

There  was  a  great  increase  in  the  quantity  of  the  urine  by 


OR   RHEUMATIC   FEVER.  135 

the  end  of  twenty-four  hours  in  39  cases,  by  the  end  of  forty- 
eight  hours  in  56  cases,  and  by  the  end  of  the  third  day  in  10 
cases ;  while  in  3  instances  in  which  diarrhoea  supervened,  the 
urine  remained  scanty  until  after  the  complete  subsidence  of 
the  disease.  In  29  cases  the  urine  was  not  saved,  and  there- 
fore the  quantity  voided  could  not  be  ascertained. 

In  37  cases  the  urine  became  clear  within  twenty-four  hours, 
in  51  within  forty-eight  hours,  in  13  within  three  days,  in  5 
within  four  days,  and  in  2  on  the  fifth  day.  In  29  cases  the 
urine  was  not  saved,  and  therefore  this  point  could  not  be 
determined.  In  several  of  these  it  probably  remained  turbid 
for  a  longer  period. 

It  lost  its  acidity,  and  became  either  alkaline  or  neutral, 
within  twenty-four  hours  in  14  instances ;  on  the  second  day, 
in  44  instances  ;  on  the  third  day,  in  12  instances ;  on  the  fourth 
day,  in  15  instances;  and  subsequently  to  that  period,  in  4 
instances.  In  19  instances  it  never  altogether  lost  its  acidity, 
and  in  29,  as  the  urine  was  not  saved,  the  fact  could  not  be 
ascertained. 

The  pain  was  relieved,  and  the  articular  infiammation  greatly 
subdued  within  twenty-four  hour.s  in  54  cases,  within  forty- 
eight  hours  in  56  other  cases,  within  three  days  in  15  cases, 
within  four  days  in  9  cases,  and  within  five  days  in  3  cases. 

The  articular  inflammation  subsided  altogether  within  twenty- 
four  hours  in  7  instances,  within  forty-eight  hours  in  26 
instances,  within  three  days  in  33  instances,  within  four  days 
in  20  instances,  within  five  days  in  13  instances,  within  seven 
days  in  14  instances;  and  in  the  remaining  24,  although  it  did 
not  wholly  subside  until  a  later  period,  yet  it  did  not  display 
any  symptoms  of  activity  after  the  fourth  day. 

In  7  instances  only  did  the  medicine  produce  any  disagree- 
able effect.  In  all  these  it  gave  rise,  in  the  first  instance,  to 
nausea,  and  in  2  to  occasional  vomiting.  In  3  of  these  7  cases 
the  nausea  subsided  after  the  first  few  doses  ;  in  the  other  four, 
which  were  among  those  in  which  the  articular  inflammation 
was  not  wholly  subdued  until  the  end  of  the  seventh  day  or 
afterward,  the  salines  had  to  be  omitted,  not  only  on  account 


136         TREATMENT  OF  ACUTE  RHEUMATISM. 

of  the  continued  nausea,  but  because  of  their  purgative  action. 
These  were  invariably  the  cases  in  Tvhich  the  remedial  power 
of  the  salines  was  least  strikingly  displayed ;  and  I  cannot  help 
thinking  that  the  Avant  of  success  depended,  as  in  many  of  the 
cases  treated  by  lemon-juice,  upon  the  absence  of  a  sufficiently 
active  converting  power  in  the  system.  The  salt  was  not 
assimilated  and  decomposed,  and  therefore  did  not  act  as  an 
alkali,  but  accumulated  in  the  system  and  operated  as  a  purga- 
tive. This  at  least  is  certain,  that  in  the  cases  alluded  to  it 
exercised  far  less  control  than  usual  over  the  acidity  of  the 
secretions,  and  failed  to  produce  much  action  as  a  renal  depu- 
rant. 

The  only  uncertainty  attaching  to  any  of  the  above  stated 
results,  is  that  arising  from  the  difficulty  in  arriving  at  a  correct 
conclusion  respecting  the  quantity  of  urine  passed.  In  no  case 
can  this  be  ascertained  with  accuracy,  as  it  is  often  impossible 
to  catch  the  urine  which  is  voided  at  stool  by  a  patient  laboring 
under  acute  rheumatism.  In  every  instance,  however,  great 
care  was  taken  to  obtain  as  close  an  approximation  to  the  truth 
as  possible. 

In  89  cases,  not  only  was  the  quantity  of  urine  increased, 
but  its  solid  constituents,  as  shown  by  its  increased  specific 
gravity,  were  also  greatly  augmented.  In  14  of  the  other  19 
cases,  although  the  urine  increased  in  quantity,  there  was  only 
a  slight  corresponding  increase  in  its  specific  gravity,  and  in  5 
the  specific  gravity  was  slightly  diminished.  This  variation  in 
the  quantity  of  the  solid  matters  excreted  by  the  kidneys  was 
attributable,  I  believe,  not  to  any  difierence  in  the  quantity  of 
the  morbific  matter  present  in  the  system,  but  to  the  varying 
activity  of  the  cutaneous  and  intestinal  secretions,  whereby  it 
happened  that  in  certain  cases  a  far  larger  amount  of  matter 
was  carried  ofi"  by  those  channels  than  could  be  so  got  rid  of  in 
others. 


CHAPTER  VI. 

ON  THE  CAUSES  OF  RHEUMATIC  AFFECTION  OF  THE  HEART. 

My  remarks  on  acute  rheumatism  have  been  hitherto  con- 
fined to  cases  in  which  pain,  redness,  and  swelling  of  the  joints 
constitute  the  only  local  manifestations  of  the  disease.  These 
external  symptoms  were  long  regarded  as  making  up  the  sum 
and  substance  of  the  complaint,  the  very  existence  of  its  inter- 
nal complications  having  been  unsought  for  and  undiscovered. 
But  clinical  observation  and  pathological  research  have  now 
unfolded  changes  in  the  internal  organs  of  the  deepest  import ; 
they  have  discovered  the  important  and  fearful  fact  that, 
accompanying  the  paroxysm  of  rheumatic  fever,  there  may  be 
not  only  articular  redness  and  swelling,  but  inflammation  of 
the  lining  and  investing  membranes  of  the  heart, — inflamma- 
tion of  an  organ,  the  mechanism  of  which  is  most  easily 
deranged,  and  which,  when  deranged,  "  lays  its  own  hard  con- 
ditions upon  the  continuance  of  a  man's  life,  and  almost  settles 
beforehand  the  manner  of  his  death."  ^ 

Inflammation  of  the  heart  is  now  recognized  as  imparting  to 
acute  rheumatism  its  chief  danger  and  perplexity.  Does  a 
patient  die  during  the  first  violence  of  the  attack  ?  his  death  is 
almost  invariably  attributable  to  inflammation  of  this  organ^ 
Does  be  apparently  recover  and  resume  his  wonted  avocations  ?; 
he  is  taught,  alas  !  at  no  distant  period,  that  there  is  yet  in^ 
store  for  him  a  frightful  amount  of  suff'ering,  a  long  continu- 
ance of  asthma,  palpitation,  and  dropsy,  as  the  result  of  his 
former  cardiac  affection. 

Such  being  the  dangers,  and  such  the  suff'ering  attaching  to 
rheumatic  cardiac  affection,  it  behooves  us  to  investigate  the 
cause  of  its  occurrence,  the  class  of  cases  in  which  it  is  most 

'  Dr.  Latham's  "Clinical  Medicine,"  p.  156. 
10 


138  ON    THE    CAUSES    OF 

liable  to  arise,  and  the  possibility  of  guarding  against  its  inva- 
sion. 

The  first  question  which  arises  is  as  to  the  cause  of  its  occur- 
rence. On  what  does  rheumatic  inflammation  of  the  heart 
depend  ?  ^ 

It  was  formerly  supposed  to  be  due  to  metastasis,  or,  in  other 
words,  to  the  retrocession  of  the  disease  from  the  external  parts, 
and  its  consequent  transfer  to  the  membranes  of  the  heart. 
But  more  recent  and  more  extended  observation  has  shown 
that  endocardial  or  exocardial  inflammation  may  occur  as  the 
first,  and,  for  some  time,  the  only  local  symptom  of  the  disease  f 
that  it  sometimes  precedes,  by  several  days,  the  access  of  artic- 
ular redness  and  swelling,  and  that  even  in  cases  where  it  does 
not  take  place  until  after  inflammation  of  the  joints  has  been  set 
up,  it  is  rarely  preceded  or  accompanied  by  subsidence  of  the 
previously  existing  articular  mischief.  In  other  words,  it  has 
shown  that,  in  the  great  majority  of  cases,  no  connection  can 
be  traced  between  the  two  sets  of  actions,  beyond  their  origin 
in  one  common  source  of  mischief — in  one  poison  which  excites 
inflammation  now  at  one  spot,  now  at  another ;  at  one  time 
attacking  several  joints  simultaneously  or  in  succession,  and 
then    the    investing    or    lining    membranes  of  the  heart ;    at 

1  Throughout  this  chapter  I  make  use  of  the  expressions  '•inflammation  of 
the  heart"  and  "  cardiac  inflammation,"  as  applying  indifi"erently  to  inflamma- 
tion of  the  endocardial  or  exocardial  membranes. 

2  Five  instances  of  this  sort  have  fallen  under  my  own  observation.  In  two 
cases  the  patient  labored  under  pericarditis  two  days,  in  another  three  days, 
and  in  another  five  days,  prior  to  the  appearance  of  articular  inflammation  ; 
while  in  another,  the  case  recorded  at  p.  288  of  this  Treatise,  the  heart  ap- 
pears to  have  been  attacked  seven  days  before  rheumatism  manifested  itself 
externally.  My  colleague.  Dr.  Wilson,  has  recorded  another  very  striking 
case  in  point,  in  the  "  Lancet''  for  November.  1844,  vol.  ii,  p.  217.  Dr.  Dundas, 
Physician  to  the  Northern  Hospital,  at  Liverpool,  has  favored  me  with  the  par- 
ticulars of  another:  one  is  quoted  in  Dr.  Graves's  "  Clinical  Medicine,"  ed.  2, 
vol.  ii,  p.  160  ;  one  by  Dr.  Watson,  in  his  "  Practice  of  Physic,"  vol.  ii,  p.  284  : 
one  by  Dr.  Hope,  in  his  "Treatise  on  the  Heart,"  ed.  3,  p.  178;  one  bj'  Dr. 
Duncan,  in  the  "Edinburgh  Med.  and  Surgical  Journal"  for  1816;  one  by  M. 
Hache,  in  the  -'Archives  Gcnerales  de  Mcdecine,"  vol.  ix,  p.  325;  and  two 
others  by  Dr.  Taylor,  of  HuddersBeld,  "  .Medico-Chir.  Trans.,"  vol.  xxviii,  p. 
527.  Some  interesting  remarks  on  this  subject  are  to  be  found  in  the  "  Edin- 
burgh Monthly  Journal,"  3d  series,  vol.  xvi,  p.  45 ;  and  others  are  recorded  in 
various  medical  periodicals. 


RHEUMATIC    AFFECTION    OF   THE    HEART.  139 

another,  reversing  the  order  of  its  attack,  and  exciting  inflam- 
mation first  of  the  heart  and  then  of  the  articular  structures. 
Hence,  although  rheumatic  inflammation  of  the  heart  may  pos- 
sibly be  connected,  in  some  rare  instances,  with  the  sudden 
subsidence  of  articular  inflammation,  and  the  transfer  of  irrita- 
tion from  the  external  parts,  it  must  be  regarded,  in  most 
instances,  as  a  mere  coincidence,  and  as  an  extension  of  the 
local  manifestations  of  the  disease. 

I  have  thought  it  right  to  be  thus  explicit  in  stating  my  con- 
viction as  to  the  true  pathology  of  this  disease,  because  a  clear 
and  full  understanding  on  this  point  is  essential  to  a  correct 
appreciation  of  many  circumstances  having  an  immediate  and 
practical  bearing  on  the  questions  at  issue,  namely,  the  class  of 
cases  in  which  cardiac  inflammation  is  most  liable  to  arise,  and 
the  possibility  of  guarding  against  its  occurrence.  If,  as  I  be- 
lieve, it  is  annexed  to  the  same  pathological  condition  of  the 
system,  and  arises  from  the  same  cause  as  inflammation  of  the 
joints,  it  is  fair  to  presume  that  much  important  information 
respecting  it  may  be  obtained  by  a  close  observation  of  the 
circumstances  which  influence  the  articular  inflammation.  If, 
like  the  external  redness  and  swelling,  this  internal  inflamma- 
tion be  due  to  the  irritation  of  a  materies  morbi  present  in  the 
blood,  and  circulating  with  it  to  every  part  of  the  body,  then 
we  may  infer  that  those  causes  which  determine  the  access  of 
inflammatory  action  about  the  joints,  and  which  modify  its 
course,  will,  in  this  case  also,  exert  a  controlling  or  modifying 
power. 

What,  then,  are  the  facts  with  regard  to  the  articular  inflam- 
mation ? 

It  occurs  most  frequently  and  most  extensively  in  cases 
remarkable  for  the  severity  of  their  general  symptoms ;  in  which, 
therefore,  there  is  great  abundance  of  the  materies  morbi,  or  a 
state  of  system  peculiarly  susceptible  of  its  influence.  It  does 
not  attack  all  the  joints  indiscriminately,  but  selects  diff'ercnt 
joints  in  diff'erent  cases ;  those  which  are  most  used,  or  which 
have  been  the  seat  of  injury  or  irritation,  being  more  than  or- 
dinarily liable  to  its  invasion.     It  attacks  a  larger  number  of 


140  ON   THE    CAUSES    OF 

joints,  and  is  more  likely  to  invade  any  particular  joint,  in 
proportion  as  the  local  symptoms  are  more  migratory ;  and 
lastly,  it  may  be  in  great  measure  prevented  and  subdued  by 
the  use  of  alkaline  and  opiate  fomentations,  and  by  the  exhi- 
bition of  medicines  which  serve  to  counteract  the  rheumatic 
poison,  to  promote  its  elimination,  and  to  prevent  its  further 
formation.^  Hence  it  appears  that  cardiac  inflammation  should 
occur  most  frequently  in  cases  characterized  by  great  febrile 
disturbance,  and  by  the  number  and  intensity  of  the  articular 
inflammations ;  that  as  in  most  attacks  of  acute  rheumatism 
some  joints  usually  escape  unscathed,  so  also  the  heart  should 
sometimes  remain  unaffected  throughout;  that  it  should  be  most 
liable  to  be  attacked  when  the  local  symptoms  of  the  disease 
are  shifting  or  migratory,  and  when,  either  from  some  consti- 
tutional peculiarity  or  from  extraneous  and  temporary  causes, 
its  irritability  is  unusually  exalted ;  and  that  it  should  be  pro- 
tected by  the  exhibition  of  such  medicines  as  are  calculated  to 
exercise  a  sedative  influence  over  it,  to  counteract  or  destroy 
the  irritant  property  of  the  rheumatic  element,  and  to  promote 
its  elimination  from  the  system. 

Some  diff'erence  of  opinion  has  been  expressed  as  to  the  ex- 
istence of  any  peculiar  proneness  to  heart  disease  among  the 
severer  examples  of  acute  rheumatism,  and  no  less  authorities 
than  Dr.  Latham  and  Dr.  Watson  have  stated  that  "pericar- 
ditis is  not  more  to  be  looked  for  when  the  disease  (rheumatism) 
is  severe  than  when  it  is  mild."  If,  by  this  assertion,  they 
mean  that  pericarditis  is  not  invariably  an  accompaniment  of 
severe  articular  rheumatism,  and  occurs  not  unfrequently  when 
the  articular  symptoms  are  slight,  or  altogether  absent,  I  en- 
tirely concur  in  their  opinion.  But  it  is  quite  inconsistent 
with  my  observation  to  believe  that  it  often  occurs  in  cases 
which  are  not  characterized  by  active  symptoms  of  disease. 
Whenever  I  have  met  with  it,  even  though  the  articular  inflam- 
mation may  have  been  slight  or  evanescent,  the  febrile  disturb- 
ance has  always  been  severe,  and  accompanied  by  profuse  and 
sour-smelling  perspiration.  As  many  as  114  out  of  the  130 
1  For  illustrations  of  this  fact,  see  Cap.  V,  pp.  119-13G  of  this  Treatise. 


RHEUMATIC   AFFECTION    OF   THE   HEART.  141 

cases  of  recent  heart  affection  observed  among  the  rheumatic 
patients  admitted  into  St.  George's  Hospital  during  the  time  I 
held  the  office  of  Registrar,  occurred  in  the  acute  form  of  the 
disease ;  and  taking  pericarditis  alone,  39  cases  were  noted 
among  the  class  of  acute  rheumatism,  and  2  only  among  the 
subacute ;  the  number  of  patients  in  the  respective  classes 
being  246  and  133.  In  other  words,  these  cases  show  that 
whereas  pericarditis  occurs  once  in  about  every  6*3  patients 
suffering  from  acute  rheumatism,  it  does  not  accompany  above 
one  in  every  Q'o-b  cases  of  the  subacute  form.  Nor  is  the  result 
of  my  experience  inconsistent  with  that  of  other  observers. 
Among  114  cases  of  articular  rheumatism  recorded  by  M. 
Bouillaud,  there  were  74  of  great  or  medium  intensity,  and  40  of 
a  slighter  description  ;  and  among  the  first  there  occurred  64 
in  which  the  existence  of  pericarditis  or  endocarditis  was  certain, 
and  3  in  which  it  was  doubtful,  while  among  the  40  of  the 
second  class  its  existence  was  only  once  discovered.^  Dr. 
Macleod,  without  giving  any  statistics  on  the  subject,  says,  very 
decidedly,  "  according  to  ray  experience,  the  heart  affection  is 
more  frequent  in  severe  than  in  mild  cases  of  rheumatism."^ 
Dr.  Copland  is  of  the  same  opinion.^  Dr.  Wm.  Budd  believes 
"  that  rheumatic  inflammation  of  the  heart  is  most  common  in 
severe  cases,  especially  when  there  is  much  fever,  and  the  parts 
affected  are  numerous  ;"^  and  Dr.  Barclay,  my  successor  as  Medi- 
cal Registrar  at  St.  George's  Hospital,  states  that,  "  until 
very  recently,  he  had  never  seen  inflammation  of  the  heart 
commence  in  the  subacute  form  of  the  disease."^ 

Every  fact,  then,  in  regard  to  rheumatic  inflammation  of  the 
heart  is  strictly  in  accordance  with  what  we  are  led  by  analogy 
to  expect.  In  many  instances  the  heart  remains  unaffected 
throughout  the  attack ;  and  though  it  does  sometimes  suffer, 
even  in  the  milder  cases,  it  is  most  commonly  damaged  in  those 
instances  which  are  marked  by  unusual  severity  of  their  gen- 

1  "  Traite  Cliniqne  du  Rheumatisme,"  Preface,  p.  12. 

2  On  ''  Rheumatism,"  p.  45. 

^  "Medical  Dictionary,"  vol.  ii,  p.  195. 
*  "Library  of  Medicine,"  vol.  v,  p.  199. 
5  "  Med.-Chir.  Trans.,"  vol.  xxxv,  note,  p.  14. 


142 


ox    THE    CAUSES    OF 


era!  symptoms,  by  the  number  and  intensity  of  the  articular 
inflammations,  and  by  the  rapidity  and  frequency  of  their 
migration. 

So  far  the  analogy  is  complete.  The  next  question  to  be 
decided  is,  in  what  cases  and  under  what  circumstances  the 
heart's  irritability  is  greatest,  and  whether  it  is  in  such  that 
the  risk  of  inflammation  in  that  organ  is  most  imminent  ? 

Experience  and  observation  have  long  since  supplied  abund- 
ant data  for  a  solution  of  this  problem.  It  is  notorious  that 
in  youth  the  heart's  action  is  not  only  quicker  than  in  more 
advanced  life,  biit  is  also  much  more  readily  accelerated.  In 
women,  in  like  manner,  the  heart  is  acted  on  more  readily  than 
in  men,  or,  in  other  words,  is  more  irritable,  and  more  easily 
excited.  In  those  persons,  again,  who  have  been  weakened  by 
illness,  or  by  large  and  repeated  bleedings,^  and  in  those  pecu- 
liar states  of  system  Avhich  are  marked  bj'  a  deficiency  of  red 
globules  in  the  blood,  the  heart's  irritability  is  much  increased, 
and  palpitation  is  readily  induced.  These,  then,  are  the  cases, 
theoretically  at  least,  in  which  cardiac  inflammation  should  be 
most  liable  to  arise.  And  so  in  practice  they  are  found  to  be. 
It  is  now  generally  admitted  that  inflammation  of  the  heart  is 
a  much  more  frequent  concomitant  of  acute  rheumatism,  when 
occurring  in  youth,  than  when  occurring  in  those  more  advanced 
in  years.-     Statistical  observations  have  shown  that  it  is  more 


^  The  experiments  of  Jlessrs.  Andral  and  Gavarret,  recorded  in  the  "  Annales 
de  Chimie,''  vol.  Ixxv,  prove  most  conclusively  that  bleeding  diminishes  the 
number  of  corpuscles  to  a  remarkable  extent,  and  in  that  respect  brings  the 
blood  into  a  condition  resembling  the  blood  in  anaemia,  in  which  the  heart  is 
peculiarly  irritable.     Three  of  these  experiments  give  the  following  results: 


Amount  of  glo-  "|    Case  i. 
bules  in  1,000  I      "    ii. 
parts  of  blood  j       "  iii. 

1st  Bleeding. 

2d  Bleeding. 

3d  Bleeding. 

4th  Bleeding. 

114-8 
12.^-3 
IL'S-V 

111-0 
124-9 
120-7 

102-8 
121-4 
112-8 

88  7 

99  6 

101  0 

Messrs.  Becqucrel  and  Rodier  also  sum  up  the  result  of  their  experiments  by 
stating  "  the  effect  of  venesection  is  to  cause  a  great  diminution  of  the  corpus- 
cles, while  it  only  slightly  lessens  the  amount  of  albumen."  (Simon's  ■'  Chem- 
istry," vol.  i,  p.  2.-)0.) 

-  Dr.  Watson,  Dr.  Macleod,  Dr.  Todd,  and  others  bear  witness  to  this  im- 
portant and  significant  fact. 


RHEUMATIC    AFFECTION    OF   THE    HEART.  143 

common  in  women  than  in  men  ;•  and  I  have  always  been  struck, 
both  in  private  practice  and  in  the  wards  of  St.  George's  Hos- 
pital, by  the  frequency  of  its  occurrence  in  the  pale  and  weakly, 
in  those  who  have  been  reduced  by  previous  illness  or  exhausted 
by  the  treatment  adopted,  and,  ca'teris  paribus,  in  those  in  whom 
the  heart's  action  is  particularly  accelerated.  Indeed,  I  believe 
that  after  carefully  weighing  these  several  circumstances,  after 
considering  the  age  and  temperament  of  the  patient,  his  pre- 
vious condition,  the  violence  of  the  attack,  the  state  of  the 
pulse,  and  the  plan  of  treatment  about  to  be  adopted,  it  is 
possible  to  predict,  with  tolerable  certainty,  the  occurrence  or 
non-occurrence  of  cardiac  inflammation. 

It  would  appear,  then,  that  whenever  the  heart's  irritability 
is  great,  the  rheumatic  poison  must  be  peculiarly  prone  to 
attack  that  organ  on  the  same  principle  as  it  is  to  invade  a 
joint  which  has  been  previously  strained,  or  is  constantly  used ; 
and,  therefore,  that  anything  which  tends  to  augment  the 
heart's  irritability,  must  tend,  pro  tanto,  to  render  the  patient 
liable  to  heart  affection ;  while  anything  having  an  opposite 
tendency  must  serve,  in  some  measure,  to  shield  him  from  such 
a  complication.  Hence,  although  a  moderate  venesection  may 
be  necessary  sometimes  for  the  relief  of  local  symptoms,  and 
for  the  purpose  of  facilitating  the  action  of  remedies,  yet 
excessive  bleeding,  by  inducing  irritability  of  the  heart,  cannot 
fail  to  predispose  to  cardiac  affection  ;  excessive  purgation  must, 
for  the  same  cause,  have  a  similar  effect,  and  so  must  every- 
thing which  has  a  like  tendency.  On  the  other  hand,  alkalies, 
freely  administered,  by  correcting  the  morbid  condition  of  the 
blood,  and  promoting  the  elimination  of  the  materies  morbi, 
directly  tend  to  obviate  inflammation  by  removing  its  cause, 
while  with  opium,  colchicum,  and  other  medicines,  they  exert 
a  sedative  influence  over  the  heart,  and  thus,  in  some  measure, 
protect  it  from  danger. 

In  thus  enunciating  my  views  on  the  subject  under  consid- 

1  See  Cap.  ix,  of  this  Treatise,  pp.  280-4. 


144  ON   THE    CAUSES    OF 

eration,  I  liave  purposely  avoided  discussing  the  oft-mooted 
question,  as  to  whether  a  proneness  to  inflammation  of  the 
heart  may.  or  may  not,  be  induced  by  venesection.  A  dis- 
cussion of  this  sort  cannot  be  decided  by  reference  to  any 
moderate  number  of  cases,  and  but  little  if  any  good  can  result 
from  an  inquiry  based  upon  uncertain  and  questionable  grounds. 
I  have,  therefore,  contented  myself  with  pointing  out  those 
facts  -which  have  appeared  to  me  most  interesting  and  sugges- 
tive ;  and  it  need  only  be  stated,  that  by  applying  the  infer- 
ences from  these  facts  to  practice,  results  have  been  obtained 
far  exceeding  in  importance  my  most  sanguine  expectations. 
Not  only  has  the  pain  been  subdued,  and  the  course  of  the  artic- 
ular inflammation  arrested  with  unusual  certainty  and  rapidity, 
but  in  almost  every  instance  the  accession  of  inflammation  of 
the  heart  has  been  prevented. 

The  treatment  which  has  proved  most  eflBcicnt  for  this  pur- 
pose is  that  which  is  directed  against  the  pathological  condi- 
tion of  the  system,  out  of  which  arises  the  tendency  to  inflam- 
mation, whether  of  the  heart,  the  joints,  or  other  parts  of  the 
body  ;  which  aims  at  neutralizing  or  counteracting  the  irritant 
property  of  the  rheumatic  poison,  at  promoting  its  elimination 
and  preventing  its  further  formation ;  and  which,  at  the  same 
time,  keeps  steadily  in  view  the  possibility  of  aflfording  protec- 
tion to  the  heart  by  a  strict  avoidance  of  everything  likely  to 
increase  its  irritability,  and  by  the  administration  of  such 
medicines  as  are  calculated  to  exercise  a  sedative  influence  over 
it.  Among  168  patients  whom  I  have  treated  for  rheumatic 
fever  since  I  first  adopted  this  plan  of  treatment,  inflammation, 
whether  of  the  pericardium  or  endocardium,  has  occurred  in 
only  31  instances,  and  in  26  at  least,  of  these,  the  heart  was 
aff'ected  before  the  patient  came  under  my  care.  In  2  of  the 
other  5  cases,  an  exocardial  murmur,  which  was  not  discovered 
when  I  first  saw  the  patient,  was  distinctly  heard  on  the  second 
day,  and  may  possibly  have  existed  in  an  incipient  state,  though 
it  escaped  detection,  on  the  first  day  of  treatment ;  in  2  others, 
an  endocardial  murmur  was  first  noticed  on  the  second  day  of 


RHEUMATIC    AFFECTION    OF    THE    HEART.  145 

treatment,  and  in  the  other,  which  is  the  case  detailed  at  p.  286, 
an  endocardial  murmur  manifested  itself  on  the  third  day  of 
treatment.  In  that  case,  however,  I  had  only  seen  the  patient 
once  before  the  commencement  of  the  cardiac  mischief,  and  I 
had  reason  to  believe  the  medicine  had  not  been  taken  regu- 
larly. In  no  other  instance  did  cardiac  inflammation  arise 
after  the  second  day  of  treatment,  or,  in  other  words,  afterthe 
patient  had  been  forty-eight  hours  under  the  influence  of  the 
remedies. 

Inflammation,  however,  is  not  the  only  form  of  disease  from 
which  the  heart  is  apt  to  suffer  in  rheumatism.  Every  one  who 
has  watched  the  post-mortem  examinations  at  any  of  our  large 
public  hospitals,  must  have  remarked  the  close  connection  sub- 
sisting between  rheumatism  and  the  formation  of  fibrinous 
vegetations  on  the  valves  and  on  the  lining  membrane  of  the 
heart.  By  common  consent  this  cardiac  aff"ection  has  been 
ascribed  to  endocardial  inflammation,  and  its  presence  has  been 
cited  as  conclusive  evidence  of  the  existence  of  endocarditis  at 
some  former  period.  Observation,  however,  has  led  me  to  take 
a  different  view  of  the  matter,  and  to  consider  that  these  fibrin- 
ous deposits,  though  common  accompaniments  of  rheumatic 
endocarditis,  are,  nevertheless,  essentially  independent  of  endo- 
cardial inflammation,  and  may  and  do  take  place  without  its 
concurrence. 

The  grounds  on  which  this  opinion  is  based  may  be  briefly 
stated.  Foremost  among  them  is  the  frequent  occurrence  of 
valvular  murmurs,  dependent  on  organic  mischief,  in  cases 
which  do  not  present  any  symptoms  of  true  cardiac  inflamma- 
tion. Thus,  frequently  during  the  active  stage  of  rheumatism, 
and  sometimes  during  recovery  from  the  disease,  while  the 
tongue  is  cleaning,  and  the  various  symptoms  are  gradually 
subsiding,  a  valvular  murmur  commences,  increases  steadily, 
and  persists  after  the  patient's  recovery.  That  in  many  of 
these  cases  the  murmur  is  not  attributable  to  inflammation, 
properly  so  called,  seems  indicated  by  the  absence  of  those 
general  and  local  signs  of  inflammation  which  are  usually  found 


146  ON   THE    CAUSES    OF 

to  accompany  endocarditis  ;^  that  it  is  caused  by  organic  mis- 
chief, is  often  rendered  probable  by  the  position  of  the  sound, 
which  is  clearly  traced  to  the  mitral  orifice,  and  is  proved  by  its 
persistence  long  after  all  symptoms  of  rheumatism  have  passed 
away;  and  that,  in  some  instances  at  least,  it  is  due  to  the 
deposit  of  fibrin  on  the  valves,  independently  of  active  valvular 
inflammation,  is  manifest  from  the  result  of  post-mortem  exami- 
nation. Indeed,  I  have  myself  met  with  two  cases  in  which  the 
valves,  though  neither  red,  swollen,  nor  thickened, — though 
not  presenting  any  trace,  however  faint,  of  true  inflammation, 
were  yet  loaded  with  a  crop  of  recent  fibrinous  vegetations.^ 
On  the  other  hand,  it  is  certain  that,  in  some  instances  at  least, 
no  unusual  eff'ects  result  from  endocarditis,  for  I  have  seen 
three  examples  of  that  disease,  marked  during  life  by  all  the 
ordinary  local  and  general  symptoms  of  inflammation,  and 
exhibiting,  after  death,  unmistakable  evidences  of  inflamma- 
tory action,  such  as  minute  capillary  injection,  with  a  swollen 
condition  of  the  valves  and  efi'usion  of  lymph  on  their  surface, 
in  two  of  which  there  was  no  trace  whatever  of  fibrinous 
deposits,  and  in  the  third  of  which  the  slightest  possible  amount 
of  deposit  existed  in  the  shape  of  small  beads  along  the  edges 
of  contact  of  the  valves.  Dr.  Ormerod  has  also  recently 
quoted  a  case,  related  by  Dr.  Kirkes,  of  true  rheumatic  endo- 
carditis, in  which  the  valves  were  distinctly  swollen  and  vascu- 
lar, and  yet  were  unincumbered  by  fibrinous  growths.^  He 
has  also  favored  me  with  the  particulars  of  another,  in  which 
a  similar  condition  was  observed.    As  then,  at  one  time,  recent 

1  That  endocarditis  may  be,  and  is  sometimes  unaccompanied  by  pain,  and 
by  other  of  the  ordinary  symptoms  of  inflammation,  is  admitted,  but  it  is  utterly 
inconsistent  with  our  knowledge  of  the  effects  of  inflammation  in  other  parts 
of  the  body,  to  suppose  that  endocarditis  is  unattended  by  active  symptoms  of 
inflammation,  so  frequently  as  the  valvular  murmurs  wliich  arise  in  the  course 
of  acute  rheumatism  would,  if  always  referable  to  inflammation,  lead  us  to 
suppose, 

^  One  of  these  was  a  case  of  pericarditis  and  pleurisy,  which  proved  fatal  on 
the  third  day  after  the  commencement  of  the  valvular  murmur;  and  one  was  a 
case  of  old-standing  heart  disease,  which  proved  suddenly  fatal,  about  a  week 
after  the  commencement  of  a  systolic  aortic  murmur. 

3  "Gulstonian  Lectures"  for  1851,  p.  29. 


KHEUMATIC   AFFECTION   OF   THE   HEART.  147 

fibrinous  vegetations  are  found  in  great  luxuriance  on  valves 
which  present  no  traces  of  inflammatory  action,  and  at  another, 
extensive  valvular  inflammation  is  seen  to  exist  without  the 
concurrence  of  such  lesions,  the  conclusion  seems  forced  upon 
us,  that  valvular  inflammation  and  fibrinous  accretions,  though 
often  coexistent  phenomena,  are  yet  essentially  independent  of 
one  another.  Indeed,  Dr.  Hope's  experiments  on  the  ass  have 
shown  that  fibrinous  vegetations  are  not  necessarily  connected 
with  inflammation  at  the  spot  where  their  formation  is  observed ; 
and  Mr.  Simon's  more  recent  experiments  not  only  lead  to  the 
same  conclusion,  but  render  it  highly  probable  that  their  occur- 
rence is  connected  with  hyperfibrinization  of  the  blood. ^  Yet 
further,  the  recent  and  very  valuable  observations  of  Dr. 
Richardson^  leave  little  room  for  doubt  that  the  absence  of  a 
due  quantity  of  ammonia  in  the  blood  will  of  itself  lead  to  a 
separation  of  the  fibrinous  element  without  the  concurrence  of 
local  inflammation.  Thus  again  we  are  directed  to  simple 
deposition  from  the  circulating  fluid  in  explanation  of  the  phe- 
nomena in  question.  Nor  does  such  an  occurrence  appear 
improbable,  when  we  consider  the  close  relationship  of  the 
endocardium  and  the  blood ;  for  what  supposition  can  be  more 
reasonable  than  that  some  change  may  be  efl'ected  in  the  blood 
in  immediate  contact  with  the  irritated  membrane,  and  that 
fibrin  may  be  deposited  in  consequence  ?  If  under  any  circum- 
stances the  deposition  of  fibrin  be  possible,  what  can  be  more 
likely  than  that  such  a  deposit  should  take  place  in  acute  rheu- 
matism when  the  blood  is  surcharged  with  the  material  in 
question,  and  when,  from  the  extreme  acidity  of  the  system,  it 
is  in  a  state  ill  calculated  to  hold  it  in  solution  ? 

That  these  fibrinous  deposits  are  connected  with  some 
abnormal  condition  of  the  circulating  fluid  seems  indicated  by 
a  fact  I  have  long  remarked,  namely,  that  they  are  almost 
entirely  confined  to  cases  accompanied  by  acute  and  wide- 
spreading  inflammation,  and  by  other  circumstances  which  are 
not  only  productive  of  unusual  quantities  of  fibrin  in  the  blood, 

^  "Lectures  on  General  Pathology,"  by  John  Simon.     London,  1850. 
2  See  the  Astley  Cooper  Prize  Essay  for  185(j. 


148 


ON   THE    CAUSES    OF 


but  probably  impair  its  solubility.^  And  since  it  has  been 
proved  by  direct  experiment  that  when  a  tendency  to  the 
deposit  of  fibrin  exists,  the  fibrinous  accretions  are  most  apt  to 
occur  on  anything  projecting  into  the  arterial  current ;  and 
further,  that  they  are  especially  prone  to  beset  those  spots 

1  During  the  time  I  held  the  office  of  Medical  Registrar  at  St.  George's  Hos- 
pital, I  observed  that  although  every  other  form  of  valvular  disease  occurred 
not  unfrequentlj-  without  any  previous  or  concurrent  inflammation,  yet  that 
no  deposit  of  fibrin  was  ever  fouud,  except  where  there  either  was  or  had  been 
rheumatism,  or  some  extensive  inflammation,  which  equally  with  rheumatic 
inflammation  implies  an  abnormal  condition  of  the  blood,  and  is  calculated  to 
increase  the  quantity,  if  not  to  impair  the  solubility  of  the  fibrin.  From  the 
statistics  which  have  been  since  published  by  my  friend  Dr.  Barclay,  who 
succeeded  me  as  Medical  Registrar  of  the  hospital,  (''  Medico-Chir.  Trans.,'' 
vol.  xxxi,)  a  further  confirmation  of  my  views  may  be  deduced,  for  in  every 
instance  in  which  fibrinous  deposits  were  found  on  the  valves  there  either  ex- 
isted or  had  previously  existed  some  such  mischief.  This  will  be  seen  on  ref- 
erence to  the  subjoined  facts.  Out  of  7.")  cases  of  valvular  disease  examined 
after  death  at  St.  George's  Hospital,  21  were  instances  of  fibrinous  deposits. 
The  historv  of  these  21.  cases  is  as  follows  : 


Recent  Rheumatic  Fever. 
Old  Rheumatic  Fever 


RecentPcricarditis,  Pleurisy,  and  Pneu- 
monia. 
Recent  Pleurisy,  and  adhesions  resulting 
from  a  former  attack  of  Pleurisy. 

3.  I  "  "  Recent  Pericarditis. 

4.  \  "  "  Pneumonia. 

5.  /  "  "  Recent  Pericarditis,  and  adhesions  result- 
ing from  a  former  atfiick  of  Pericarditis. 

Recent   Pericarditis,   Pleurisy    and   Pneu- 
monia. 

7.  I  "  "  Recent  Pericarditis  and  Pleurisy. 

8.  I  "  "  Old  adhesions  resulting  from  former  attacks 

of  Pleurisy  and  Pericarditis. 

9.  \  "  "  Pneumonia,  and   adhesions  resulting  from 

former  Pleurisy  and  Pericarditis. 

10.  /  Rheumatic  Fever,  doubtful.  Pneumonia  and  Inflammation  of  the 
\  Brain. 

11.  /  "  "  Pneumonia  and  recent  Pericarditis. 

12.  /  "  "  Adhesions,  the  result  of  a  former  at- 
\  tack  of  Pleurisy. 

13.  /  No  mention  of  Rheumatic  Fever.  Adhesions,  the  result  of  a  former 
j  attack  of  Pleurisj-.  Diseased 
\  Kidneys. 

14.  (  "  "  Recent  Pericarditis,  Pleurisy  and 
y  Pneumonia,  and  adhesions,  the 
I  result  of  former  Pericarditis. 
\  Mottled  Kidneys. 


RHEUMATIC    AFFECTION    OF    THE    HEART.  149 

•where  irritation  has  been  excited,^  we  cannot  be  surprised  that 
they  shoukl  take  place  on  the  valves  in  which,  from  the  very 
nature  of  the  case,  the  effects  of  irritation  are  most  likely  to 
be  felt.  Indeed,  the  correctness  of  this  interpretation  is  attested 
by  their  almost  invariable  occurrence  on  that  side  of  the  valve 
against  which  the  current  of  the  blood  is  directed ;  as,  for 
instance,  on  the  auricular  surface  of  the  mitral  valve  and  the 
ventricular  surface  of  the  aortic  valves,  as  also  by  the  fact  that 
they  most  abound,  if  indeed  they  be  not  confined,  as  they  some- 
times are,  to  the  angular  projections  and  the  edges  of  contact 
of  the  valves,  which  are  the  parts  most  subjected  to  tension 
and  pressure.  If  endocarditis  be  set  up  during  the  existence 
of  a  state  of  blood  characterized,  as  the  blood  in  acute  rheu- 
matism is,  by  the  presence  of  unusual  quantities  of  fibrin,  the 
deposit  of  that  material  at  the  seat  of  inflammation  is  an  event 
in  the  highest  degree  probable ;  and  even  if  there  be  no  endo- 
cardial inflammation,  the  formation  of  such  a  deposit  on  the 
strained  and  excited  valvular  apparatus  can  hardly  be  regarded 
as  improbable.^ 

15.  /    No  Rheumatic  Fever.     Pneumonia. 

16.  /  "  "  Recent  Pleurisy,  -with  excessive  congestion 
I  of  the  Lungs,  and  adhesions,  the  result 
I  -  of  former  Pleurisy.     Diseased  Kidneys. 

17.  \  "  "         Recent  Pericarditis.     Diseased  Kidneys. 

18.  I  "  «  Pneumonia,  and  adhesions  resulting  from 
/  former  attacks  of  Pleurisy  and  Peri- 
\                                                   carditis.     Diseased  Kidneys. 

19'     1  "  "         Recent   Pleurisy,   and   adhesions    resulting 

/  from  a  former  attack  of  Pleurisy. 

20.  I  '<  "         Recent  Pericarditis. 

21.  I  "  "  Adhesions  resulting  from  a  former  attack 
\  of  Pleurisy. 

1  See  the  account  of  Dr.  Hope's  experiments  on  the  ass. 

2  Dr.  Ormerod  considers  these  growths  to  be  the  offspring  of  inflammation, 
but  he  is  obliged  to  admit  that  "  deposition  from  the  blood  is  a  process  which 
may,  and  very  often  does  take  place ;  and  as  any  roughness  on  the  surface  of 
a  valve  would  be  likely  to  attrac  fibrin  from  the  passing  blood,  even  in  a 
healthy  individual,  such  an  event  might  yet  more  readily  ensue  in  a  case 
where  the  blood  has  already  a  strong  tendency  to  deposit  fibrin.  Such  is  the 
case  in  acute  rheumatism,  as  appears  not  only  from  the  analysis  of  the  blood, 
but  from  the  large  inflammatory  exudation  into  the  pericardium  or  pleura, 
which  occurs  coincidently  in  some  such  cases."  ("Gulstonian  Lectures  "  for 
1851,  p.  30.) 


150  ON   THE   ckuSES   OF 

A  further  confirmation  of  the  opinion  I  have  advanced  is 
derived  from  the  extraordinary  difference  in  the  frequency  with 
which  inflammation  of  the  lungs  accompanies  the  various  forms 
of  rheumatic  heart  affection.  Thus,  in  rheumatism  compli- 
cated by  endocardial  affection  only,  inflammation  of  the  lungs 
or  their  membranous  envelopes  has  occurred  once  in  every  ten 
cases,  whereas  it  has  been  observed  in  rather  more  than  half 
the  cases  attended  by  pericarditis,  and  in  rather  more  than 
two-thirds  of  those  marked  by  endo-pericarditis.^  The  pulmon- 
ary inflammation  is  certainly  due  to  the  same  cause  of  irrita- 
tion as  the  cardiac  inflammation,  and  the  inflammation  on  the 
internal  surface  of  the  heart  to  the  same  as  that  on  the  external. 
If,  then,  the  organic  valvular  murmurs  be  in  all  cases  referable 
to  endocardial  inflammation,  the  difference  in  the  frequency 
with  which  pericarditis  and  endocarditis  are  respectively  ac- 
companied by  inflammation  of  the  lungs,  does  not  admit  of 
satisfactory  explanation.  Whereas,  if  my  view  as  to  the  origin 
of  these  murmurs  be  correct,  and  the  valvular  mischief  be  in 
many  cases  occasioned  by  the  deposition  of  fibrin  occurring 
independently  of  active  endocardial  inflammation,  the  apparent 
inconsistency  is  at  once  explained.  And  it  is  rendered  proba- 
ble that  the  variation  observed  in  the  proportion  which  pul- 
monary inflammation  bears  to  the  different  classes  of  heart 
affections,  may  serve  to  indicate,  with  tolerable  accuracy,  the 
frequency  with  which  valvular  mischief  arising  in  the  course  of 
rheumatism  is  referable  to  other  cases  than  true  endocardial 
inflammation. 

By  some  persons,  the  frequent  coincidence  of  pericarditis 
and  inflammation  of  the  lungs  or  their  investing  membrane  has 
been  referred  to  the  close  proximity  of  the  inflamed  parts, 
inflammatory  action  having  a  tendency  to  spread  by  contiguity 
of  structure.  But  many  years'  observation  in  the  dead-house 
of  St.  George's  Hospital  has  taught  me  to  attach  very  little 
weight  to  such  a  supposition,  and  has  induced  me  to  believe 
that  as  inflammation,  when  affecting  the  lungs,  very  rarely 
spreads  to  the  pericardium,  so  inflammation  of  the  investing 
*  For  full  particulars  on  this  subject,  see  p.  283,  of  this  Treatise. 


RHEUMATIC   AFFECTION    OF   THE    HEART.  151 

membrane  of  the  heart  has  very  little  tendency  to  spread 
either  to  the  endocardium  or  to  the  lungs,  and  that  when  such 
an  action  is  set  up  in  either  or  both  of  such  parts  coincidentlj 
■with  or  during  the  progress  of  pericarditis,  it  is  usually  caused 
by  the  same  agency  which  induced  the  original  attack  of  in- 
flammation.^ 

It  has  been  argued  that  if  these  fibrinous  growths  were  in- 
deed  the  products  of  simple  deposition  on  the  lining  membrane 
of  the  valves,  they  would  be  easily  separable  from  the  subja- 
cent tissues.  That  in  most  recent  cases  they  are  readily  sepa- 
rable from  the  subjacent  tissues  must  be  admitted,  and  I  can 
assert,  from  repeated  personal  observation,  that  in  some 
instances,  at  least,  of  older  standing,  the  fibrinous  band  which 
results  under  such  circumstances  can  be  detached  without  any 
damage  to  the  valve  beyond  that  of  separating  from  it  its  lining 
membrane.  And  this  amount  of  cohesion  does  not  necessarily 
imply  antecedent  inflammation,  inasmuch  as  fibrin  deposited 
from  the  blood  may  obviously  after  a  time  become  agglutinated 
to  the  endocardium  so  firmly  as  to  cause  this  amount  of  mis- 
chief. 

1  The  following  statistical  record  of  2G5  cases  of  recent  pneumonia,  pleurisy, 
or  pleuro-i)neumonia,  which  occurred  in  St.  Bartholomew's  Hospital,  and  with 
which  I  have  been  favored  by  my  friend  Dr.  Ormerod,  of  Brighton,  confirms 
the  result  of  my  experience  at  St.  George's.     The  265  were  thus  distributed : 
117  had  pneumonia  alone,  of  whom   19  or  1   in     6-1   had  pericarditis. 
86  had  pleurisy  alone,  "  6  or  1   in  14-3  " 

62  had  pleuropneumonia,         "  8  or  1  in     77  " 

Thus  of 

2^-  f  cases  of  recent  pulmonary  )  oo  i  '  q-  I  were  complicated  by 
I  inflammation         .         .        .  j  [  pericarditis. 

Now,  as  inflammation  must  certainly  have  as  great  a  tendency  to  spread 
from  the  lungs  to  the  heart,  as  from  the  heart  to  the  lungs,  it  would  appear 
that  the  inflammation  of  the  lungs  which  accompanies  rheumatic  pericarditis 
cannot  be  regarded  as  resulting  from  the  spread  of  pericardiac  inflammation 
in  more  than  one  in  every  eight  cases,  a  proportion  which  would  not  interfere 
materially  with  the  results  from  which  my  inferences  are  drawn.  Even  this 
proportion,  however,  is  far  higher  than  that  in  which  there  is  reason  to  believe 
such  a  spread  of  inflammation  does  actually  take  place,  for  many  of  the  33 
cases  of  pericarditis  in  the  table  were  doubtless  referable  to  the  same  cause 
which  produced  the  pulmonary  affection,  and  were  in  no  degree  attributable 
to  the  spread  of  inflammation,  in  consequence  of  the  contiguity  of  the  parts. 


152  ON   THE    CAUSES    OF 

But  the  structures  which  constitute  the  valvular  apparatus  are 
sometimes  firmly  matted  together,  and  such  a  condition  undoubt- 
edly points  to  some  antecedent  thickening  process,  probably  of 
an  inflammatory  nature.  Its  existence,  therefore,  in  the  ma- 
jority of  these  cases,  is  very  important  and  suggestive.  In 
some  instances  the  thickening  is,  doubtless,  referable  to  an 
attack  of  active  lymph-effusing  inflammation,  and  the  fibrinous 
deposits  take  place  on  the  valves  partly  as  a  result  of  the 
irritation  so  excited.  But  the  valvular  thickening  and  the 
deposition  of  fibrin  are  not  necessarily  coincident  phenomena ; 
on  the  contrary,  there  appear  strong  grounds  for  believing  that 
although  thickening  of  the  valves  may  be,  and  is  sometimes, 
the  result  of  an  active  lymph-effusing  inflammation,  occurring 
before  or  coincidently  with  the  deposition  of  fibrin,  yet  that 
not  unfrequently  it  takes  place  subsequently  to  the  deposit  of 
fibrin,  and  probably,  in  great  measure,  in  consequence  of  it. 
In  many  instances  in  which  I  have  had  an  opportunity  of 
examining  the  condition  of  the  valves  shortly  after  the  appear- 
ance of  these  fibrinous  growths,  there  has  been  little,  if  any, 
thickening  of  the  substance  of  the  valve ;  whereas,  when  the 
examination  has  not  taken  place  until  these  deposits  have 
existed  for  some  time,  some  thickening  or  matting  together  of 
the  structures  has  been  the  rule  rather  than  the  exception ;  as 
if  the  presence  of  these  abnormal  deposits  on  the  surface  of  the 
valve  is  apt  to  give  rise  to  irritation  and  gradual  thickening  of 
the  contiguous  parts. 

If,  then,  it  be  admitted  that  fibrin  may  be,  and  is,  under 
certain  circumstances,  deposited  from  the  blood  without  the 
coexistence  of  endocarditis,  it  is  obvious  tliat  if  we  would  pre- 
serve the  heart  from  mischief,  it  is  necessary  not  only  to  take 
precautions  against  inflammation,  but  to  maintain,  at  all  haz- 
ards, the  solubility  of  the  fibrin.  For  both  these  purposes, 
alkalies  and  the  neutral  salts,  if  freely  administered,  prove 
most  efficient  agents.  By  counteracting  or  destroying  the 
irritant  property  of  the  materies  morbi,  and  by  promoting  its 
elimination,  they  tend  to  prevent  articular  and  other  local 
inflammations  ;  they  thus  prevent  any  further  augmentation  in 


RHEUMATIC   AFFECTION    OF   THE    HEART.  153 

the  quantity  of  fibrin;^  and  by  increasing  as  they  do  the 
solubility  of  that  matei'ial,  they  prove  excellent  preservatives 
against  its  deposition  on  the  valves. 

My  views,  then,  in  regard  to  the  occurrence  of  rheumatic 
inflammation  of  the  heart,  may  be  briefly  stated  thus :  Its 
frequency  is  probably  referable  to  the  similarity  in  structure 
between  the  joints  and  the  investing  and  lining  membranes  of 
the  heart,  the  rheumatic  poison  having  a  special  affinity  for  the 
fibrous  and  fibro-serous  textures  throughout  the  bod}^  and  fix- 
ing more  particularly  upon  those  which  are  in  any  way  subjected 
to  irritation."  The  occurrence  of  carditis,  in  any  particular 
instance,  is  determined,  in  great  measure,  by  the  irritability 
of  the  heart,  from  whatever  cause  arising  ;  but  according  to  the 
intensity  of  the  febrile  disturbance,  so,  cseteris  paribus,  is  the 
liability  to  inflammation,  whether  of  the  joints,  the  heart,  or 
any  other  part  of  the  body,  inasmuch  as  the  violence  of  the 
febrile  symptoms  forms  a  tolerably  accurate  measure  of  the 
amount  of  the  poison  present  in  the  system,  and  of  the  patient's 
susceptibility  of  its  influence.  The  number  and  intensity  of  the 
articular  inflammations,  and  the  proneness  they  exhibit  to  shift 
their  quarters,  serve  also  as  guides  to  the  probability  of  heart  or 
other  internal  afiections,  not  only  as  indicating  the  presence 
of  a  large  amount  of  morbific  matter,  and  a  peculiar  suscepti- 
bility of  its  irritation,  but  as  showing  that  it  has  no  special 
tendency  to  become  fixed  to  any  particular  spot,  and  may, 
therefore,  seize  upon  the  heart,  or  some  other  internal  organ 
for  which  it  has  more  or  less  affinity.     Lastly,  the  extreme 

1  The  experiments  of  Messrs.  Andral  and  Gavarret  have  proved  that  the 
increase  of  fibrin  in  the  blood  of  rheumatic  patients  is  commensurate  with  the 
extent  and  intensity  of  the  local  inflammations,  and  that  the  quantity  of  fibrin 
returns  to  its  normal  standard  soon  after  the  local  inflammations  have  been 
subdued. 

'^  "  In  the  heart,  as  in  the  large  articular  structures,  the  fiber  which  rheumatic 
inflammation  most  affects  is  always  in  a  relation  of  compulsory  movement  with 
the  muscle  of  which  it  forms  a  part.  By  systole  of  the  ventricle  it  suffers  con- 
tinual attrition  in  the  pericardium,  and  in  the  cardiac  valves  maintains  its 
office  by  strain,  and  with  a  pull.  On  the  other  hand,  the  dura  mater  and  peri- 
osteum, which  no  muscular  action  is  able  to  displace,  are  (in  great  measure) 
exempted  from  the  local  inflammation  of  rheumatic  fever."  Dr.  Wilson  "  On 
the  true  Character  of  Acute  Rheumatism,"  "  Lancet"  for  1844,  vol.  ii,  p.  217.) 
11 


154  ON    THE    CAUSES    OF 

liability  to  cardiac  inflammation,  engendered  by  the  repression 
or  rapid  subsidence  of  the  articular  inflammation,  is  explicable 
by  the  greater  quantity  of  the  poison  which  is  thus  suddenly 
thrown  into  the  blood's  current. 

Respecting  fibrinous  deposition  on  the  valves,  the  following 
is  the  view  I  have  been  led  to  adopt :  It  is  due  to  the  presence 
of  an  unusual  quantity  of  fibrin  in  the  blood,  and  to  the  weak 
state  of  solution  in  which  it  is  held,  probably  in  consequence 
of  the  extreme  acidity  of  the  system  and  the  absence  of  a  due 
quantity  of  ammonia  in  the  blood  :'  it  is  essentially  independent 
of  valvular  inflammation,  and  may  or  may  not  occur  coinci- 
dently  with  it  ;  the  probability  of  its  occurrence,  however,  is 
greatly  increased  by  the  existence  of  active  valvular  inflam- 
mation, inasmuch  as  the  slightest  roughness  or  unevenness  on 
a  valve,  such  as  would  be  likely  to  arise  from  inflammation, 
would  form  a  nucleus  for  a  deposit  of  fibrin,  and  would  thereby 
favor  the  tendency  to  its  deposition.  Moreover,  its  occurrence 
must  be  rendered  probable  by  the  existence  of  active  articular 
inflammation,  inasmuch  as  such  inflammation  not  only  produces 
a  vast  augmentation  in  the  quantity  of  fibrin,  but  implies  an 
extremely  acid  state  of  the  system  in  which  the  fibrin  is  held 
in  very  weak  solution.  It  takes  place  on  the  valves  in  prefer- 
ence to  other  parts  of  the  heart,  partly  in  consequence  of  the 
extreme  susceptibility  to  the  irritation  of  the  rheumatic  poison 
exhibited  by  the  fibrous  tissue  which  enters  into  their  compo- 
sition ;  partly  in  consequence  of  the  excited  state  in  which  they 
are  kept  by  their  unusually  frequent  and  forcible  contact  with 
each  other,  and  by  the  passage  over  them  and  impulse  against 
them  of  blood  which  has  become  abnormally  irritating  in  its 
character  ;  partly,  and  also  in  consequence  of  the  strong  tend- 
ency which  exists  to  the  deposition  of  fibrin  on  anything  pro- 
jecting into  the  arterial  current."  A  further  consideration  of 
the  circumstances  under  which  these  accretions  take  place, 
serves  also   to  explain  why  the   angular  projections  and  the 

1  See  Dr.  Rickardson's  "  Aslley  Cooper  Prize  Essay"  for  1856. 

2  See  report  of  Mr.  Simon's  experiments  in  his  "  Lectures  on  General  Pa- 
thology." 


RHEUMATIC   AFFECTION    OF   THE    HEART.  155 

edges  of  contact  of  the  valves  are  frequently  loaded  with  fibrin- 
ous deposits,  while  the  surface  and  free  edges  of  the  valves, 
and  other  parts  of  the  endocardial  membrane,  retain  their 
healthy,  unincumbered  condition.  For  nothing  can  be  more 
certain  than  that  fibrinous  deposition  may  be  determined  to  a 
spot  by  any  cause  calculated  to  roughen  or  irritate  the  endo- 
cardial membrane  :  and  the  angular  projections  and  the  edges 
of  contact  of  the  valves  are  just  the*  parts  which  are  most  sub- 
jected to  tension,  attrition,  and  pressure. 


CHAPTER  VII. 

ON  RHEUMATIC  INFLAMMATION  OF  THE  HEART. 

In  the  preceding  chapter  I  have  endeavored  to  trace  the 
predisposing  cause  of  rheumatic  carditis :  in  the  present,  I 
propose  to  commence  by  a  description  of  the  organic  changes 
to  which  it  gives  rise,  and  afterward  to  proceed  to  the  expo- 
sition of  its  physical  signs  and  general  symptoms.  By  follow- 
ing this  course,  the  latter  will  he  more  readily  understood  and 
appreciated,  as  they  will  thus  he  recognized  as  the  natural 
results  of  the  local  changes  induced  in  the  heart  and  its  mem- 
branes, and  of  the  altered  mechanism  consequent  thereupon. 

It  has  been  already  stated,  that  when  in  the  course  of  acute 
rheumatism  the  heart  becomes  the  seat  of  inflammatory  action, 
its  investing  and  lining  membranes,  the  pericardium  and  the 
endocardium,  are  both  apt  to  be  implicated  in  the  mischief 
which  takes  place.  Pericarditis,  however,  is  occasionally  met 
with,  uncomplicated  by  any  other  affection  of  the  heart ;  and 
endocarditis,  in  like  manner,  may  run  its  course  without  the 
concurrence  of  inflammation  of  the  pericardium.  Under  these 
different  circumstances  lesions  are  produced,  which  differ  widely 
in  their  seat  and  character,  and  1  will  therefore  first  describe 
the  changes  produced  by  an  attack  of  pericarditis,  and  then 
proceed  to  those  resulting  from  an  invasion  of  endocarditis. 
It  will  be  necessary,  however,  to  a  full  understanding  of  the 
subject,  to  take  into  consideration  the  nature  of  the  membrane 
inflamed,  and  the  circumstances  under  which  the  inflammation 
takes  place. 

The  pericardium  is  a  serous  membrane,  and  partakes  of  the 
characters  which  belong  especially  to  that  class  of  tissues. 
Its  inflammation,  therefore,  is  of  the  adhesive  kind,  and  is 
accompanied  by  an  effusion  of  serum  or  of  plastic  lymph,  or  of 


RHEUMATIC    INFLAMMATION    OF    THE    HEART.  157 

both  these  products  in  varying  proportions  ;  or  sometimes, 
more  especially  in  unhealthy  subjects/  by  a  serous  effusion 
more  or  less  tinged  with  blood,  and  mixed  with  curdy,  ill-con- 
cocted lymph,  having  a  tendency  to  assume  a  puriform  char- 
acter. But  the  pericardium  is  not  only  a  serous  membrane,  it 
is  also  a  shut  sac,  the  two  opposed  surfaces  of  which  are  in  con- 
tact with  each  other,  and  kept  in  constant  motion,  the  one  on  the 
other,  by  the  natural  action  of  the  heart.  Hence,  although 
when  it  becomes  inflamed,  the  inflammation  may  be  sometimes 
controlled  by  judicious  treatment,  before  it  has  involved  the 
whole  extent  of  the  membrane,  yet  more  generally  the  constant 
attrition  of  the  two  inflamed  surfaces  keeps  up  and  aggravates 
the  original  mischief,  until  it  has  spread  over  the  entire  surface 
of  the  heart. 

The  effects  which  follow  an  attack  of  pericarditis  vary  accord- 
ing to  the  extent  of  the  disease  and  the  character  of  its  pro- 
ducts in  each  particular  instance.  When  the  membrane  has 
been  only  partially  implicated,  lymph  may  be  poured  out  in 
quantity  insufficient  to  cause  adhesion  between  the  two  layers 
of  membrane,  and  then  by  degrees  it  may  be  gradually  reab- 
sorbed until  a  white  patch  on  the  heart  only  remains  where  a 
thick  coating  of  lymph  had  previously  existed ;  or  it  may  be 
effused  in  larger  quantities,  and  the  inflamed  surfaces  may  be 
glued  together  at  the  seat  of  inflammation ;  or  serum  mixed 
with  only  a  small  quantity  of  lymph  may  be  effused,  distending 
the  sac  of  the  pericardium,  and  keeping  its  two  surfaces  more 
or  less  asunder,  in  which  case  adhesions  take  place  less  readily, 
and  those  which  do  occur  are  partial  and  irregular.  When  the 
entire  membrane  becomes  inflamed,  the  changes  produced  are 
proportionably  extensive.  If  the  effusion  consist  chiefly  of 
coagulable  lymph,  the  two  surfaces  may  become  agglutinated 
together  throughout  their  whole  extent ;  if  it  consist  of  lymph 
and  serum,  the   liquid   part    may  be   gradually  absorbed,  and 

1  I  say  "  in  unhealthy  subjects,"  because  these  differences  in  the  products  of 
the  same  disease  are  due  here,  as  elsewhere,  to  differences  of  constitution,  and 
to  circumstances  tending  to  influence  the  patient's  strength  ;  and  the  changes 
which  subsequently  take  place  in  the  morbid  products  are  also  governed  by 
such  peculiarities. 


158  RHEUMATIC    INFLAMMATION    OF   THE    HEART, 

universal  adhesion  may  take  place  as  before ;  while  if  it  con- 
sist chiefly  of  serum  mixed  with  pus,  or  with  shreds  of  curdy 
lymph  of  low  vitality,  or  if  the  serum  be  very  copious  and  be 
not  readily  absorbed,  adhesion  sometimes  fails  to  take  place, 
the  sac  of  the  pericardium  becomes  permanently  distended, 
and  the  heart's  action  greatly  embarrassed.  The  former  results 
are  met  with  in  the  vigorous  and  healthy ;  the  latter  are 
observed  chiefly  in  the  scrofulous,  weakly,  or  unhealthy.  In 
the  first  class  of  cases,  if  the  patient  survive  the  first  shock  of 
the  attack,  he  may  at  first  experience  little  ill  effects  from  the 
lesion  his  heart  has  sustained.  Indeed,  according  to  my  expe- 
rience, such  is  generally  the  case  Avhen  adhesion  occurs  between 
those  parts  of  the  pericardium  which  are  naturally  in  appo- 
sition ;  and  even  when  parts  not  naturally  in  apposition  have 
become  adherent,  a  temporary  and  partial  recovery  may  ensue, 
and  the  suff'erer,  though  tormented  by  palpitation  and  dyspnoea 
on  exertion,  may  yet  survive  his  attack  for  a  period  varying 
from  a  few  months  to  twelve  months,  or  even  to  several  years. 
But  in  the  second  class  of  cases  there  is  no  effort  at  recovery, 
and  the  unhappy  patient  lingers  on  a  victim  to  palpitation  and 
frightful  paroxysms  of  dyspnoea  and  suff'ocation,  until  after  the 
lapse  of  a  short  time — sometimes  in  the  course  of  a  few  days — 
his  life  and  his  suff"erings  are  terminated  rather  suddenly  by 
death. 

It  has  been  suggested  that  the  lymph  efi"used  in  pericarditis 
is  often  thoroughly  reabsorbed,  so  that  the  pericardium  is 
restored  to  the  condition  of  health,  and  perfect  recovery  takes 
place.  This  I  do  not  believe  to  be  the  case.  Doubtless  it  may 
be  reabsorbed  to  a  very  great  extent,  so  that  a  thin  layer  only 
may  remain  where  a  copious  and  thick  deposit  had  previously 
existed,  but  I  quite  agree  with  Dr.  Latham  and  Dr.  Watson 
that  adhesion,  more  or  less  general,  between  the  two  layers  of 
the  pericardium,  is  the  most  favorable  issue  we  are  justified  in 
expecting,  when  inflammation  has  been  extensively  diff"used  over 
the  membrane.  For  although  we  see  and  know  that  the  lymph 
poured  out  in  iritis  idsappears,  and  are  bound  to  admit  that 
there  is  no,  a  priori,  impossibility  in  the  reabsorption  of  the 


ITS    PATHOLOGICAL    EFFECTS.  159 

lymph  effused  in  pericarditis,  still  the  improbability  is  so  great 
as  to  amount  almost  to  an  impossibility.  In  iritis,  the  inflamed 
parts  may  be  kept  tolerably  at  rest,  and  the  inflammation 
speedily  subdued,  and  as  the  quantity  of  lymph  exuded  is  com- 
paratively small,  its  absorption  may  be  effected  under  the  influ- 
ence of  mercury  before  it  has  time  to  become  organized.  But 
in  pericarditis  the  constant  attrition  of  the  two  inflamed  sur- 
faces keeps  up  and  aggravates  the  existing  inflammation,  so 
that  it  endures  for  a  lengthened  period ;  the  lymph  is  usually 
poured  out  in  very  large  quantities,  and  in  healthy  persons, 
when  its  vitality  is  great,  shows  a  strong  disposition  to  become 
organized,  and  as  the  two  surfaces  of  membrane,  each  loaded 
with  a  layer  of  this  plastic  medium,  are  constantly  in  appo- 
sition, it  is  difiicult  to  conceive  how  they  can  fail  to  become 
adherent.  But  our  post-mortem  records  show  clearly  and  indis- 
puial)ly  that  a  small  and  partial  effusion  of  lymph  may  some- 
times accompany  pericarditis,  and  that  not  unfrequently  the 
lymph  is  curdy  and  but  slightly  plastic.  In  both  these  cases 
adhesions  may  fail  to  take  place.  In  the  first,  because  the 
lymph,  even  if  plastic,  is  not  in  quantity  sufiicient  to  restrain 
the  to-and-fro  motion  of  the  two  surfaces  of  the  membrane.  In 
the  last,  because  it  is  from  its  nature  but  little  disposed  to  form 
adhesions,  and,  moreover,  is  almost  invariably  accompanied  by 
a  copious  eff*usion  of  serum,  which  keeps  the  two  surfaces  of 
the  pericardium  asunder,  until  by  continued  washing  it  is  ren- 
dered shreddy,  and,  for  the  most  part,  inapt  for  the  purpose  of 
adhesion.  In  such  cases,  doubtless,  absorption  of  the  lymph 
is  gradually  eff'ected  to  a  very  great  degree,  and  some  loose 
membranous  bands,  or  a  few  white  patches  only  are  left,  such 
as  have  been  well  described  by  Mr.  Paget,  in  volume  xxiii 
of  the  "  Medico-Chirurgical  Transactions."  But  inordinary 
cases,  when  extensive  pericarditis  occurs  in  healthy  persons,  a 
large  quantity  of  highly  plastic  lymph  is  poured  out,  and  then 
so  rapidly  does  adhesion  take  place  and  organization  of  the 
plastic  medium  commence,  that  I  look  upon  its  complete  absorp- 
tion as  next  to  impossible. 

Thus,  then,  to  speak  in  general  terras,  the  primary  effects 


160  RHEUMATIC    INFLAMMATION    OF   THE    HEART, 

produced  by  extensive  inflammation  of  the  investing  membrane 
of  the  heart  are — first,  off'usion  either  of  lymph  or  scrum,  or  of 
serum  mixed  with  coaguhible  lymph,  or  with  curdy,  ill-concocted 
lymph,  or  with  more  or  less  blood  or  pus :  and  then  either 
absorption  of  the  liquid,  and  adhesion  of  the  pericardium  to 
the  heart  over  a  greater  or  less  extent,  or  else  a  still  further 
continuance  of  effusion,  and  death  as  its  natural  consequence. 
It  must  not  be  imagined,  however,  that  death  occurs  only  in 
cases  accompanied  by  an  abundant  liquid  effusion,  for  although 
these  are  generally  the  most  unfavorable  instances,  yet  fatal 
results  are  sometimes  met  with  even  when  little  else  than  lymph 
has  been  poured  out.  Nor  does  the  fatal  issue  occur  at  any 
particular  period  of  the  attack  ;  rarely,  indeed,  does  it  take 
place  at  a  very  early  date,  but  it  sometimes  happens  before, 
sometimes  not  until  after  adhesion  has  taken  place.  Thus  the 
morbid  appearances  observed  on  dissection  vary  both  w-ith  the 
character  of  the  inflammation  and  with  the  period  at  w^hicli  the 
attack  has  proved  fatal.  If  death  has  occurred  early,  traces 
of  inflammation  may  be  often  observed  even  before  cutting  into 
the  bag  of  the  pericardium.  Lymph  and  serum,  and  sometimes 
pus,  may  be  found  effused  into  the  anterior  mediastinum,  while 
the  pericardium  itself  is  distended  with  fluid,  or  if  not  much 
distended,  is  soft  and  pulpy  to  the  touch.  And  no  sooner  is 
its  cavity  laid  open  than  the  reason  of  this  abnormal  condition 
is  apparent.  In  the  former  cases  it  will  be  found  to  contain 
an  enormous  collection  of  serum,  sometimes  clear,  more  often 
turbid,  generally  containing  flakes  of  lymph,  not  unfrequently 
tinged  with  blood ;  and  when  this  is  allowed  to  escape,  the  sur- 
face of  the  membrane  will  be  seen  highly  vascular,  and  covered, 
over  a  greater  or  less  extent,  by  a  coating  of  recent  coagulable 
lymph.  In  the  latter  cases  a  small  quantity  only  of  liquid 
effusion  Avill  be  found,  but  a  large  amount  of  plastic  lymph, 
often  tinged  or  mottled  with  blood,  will  be  seen  deposited  in 
successive  layers  on  the  internal  surface  of  the  sac.  And  a 
very  peculiar  appearance  this  lymph  presents.  The  constant 
motion  and  attrition  of  the  parts  prevent  its  forming  a  smooth 
surface,  and  its  appearance  varies  according  to  the  amount  of 


ITS    PATHOLOGICAL    EFFECTS.  161 

serum  present  and  to  the  vitality  of  the  more  solid  exudation. 
If  it  be  of  low  vitality,  it  adheres  very  loosely  to  the  membrane 
which  exudes  it;  much  of  it  is  detached  by  the  motion  of  the 
heart,  and  floats  in  loose  shreds  in  the  surrounding  serum, 
while  that  which  still  remains  adherent  to  the  membrane  is 
rough,  loose,  and  shaggy.  If  it  be  more  highly  organizable, 
and  serum  be  present  in  sufficient  quantity  to  keep  the  two 
sides  of  the  sac  asunder,  and  thus  prevent  their  immediate  adhe- 
sion, then  it  is  thrown,  by  the  action  of  the  heart,  into  rough  and 
irregular  transverse  ridges.  If,  on  the  other  hand,  there  be 
little  serum  present,  and  the  membrane  be  covered  with  a  thick 
coating  of  highly  plastic  lymph,  then  is  the  tendency  to  adhe- 
sion great ;  very  slight  lateral  motion  of  the  membrane  can 
take  place,  and  a  spongy,  or  honey-comb,  or  tripe-like  appear- 
ance is  produced  by  the  repeated  contact  and  separation  of  the 
two  inflamed  surfaces. 

These  are  the  appearances  observed  when  the  patient  falls  an 
early  victim  to  the  attack  ;  but  when  he  dies,  as  he  sometimes 
does,  at  a  later  stage  of  the  complaint,  soon  after  the  pericar- 
dium has  become  adherent  to  the  heart,  there  are  other  points 
worthy  of  observation.  The  medium  of  adhesion  will  be  found 
to  consist  of  plastic  lymph,  still  soft  and  easily  broken  down  ; 
and  which,  on  more  than  one  occasion,  I  have  known  to  give 
way  during  life  on  the  speedy  recurrence  of  pericardial  inflam- 
mation. But  in  this  lymph  may  be  seen  here  and  there  some 
bloody  spots  or  streaks,  or  anastomosing  red  lines,  the  first  in- 
dications of  its  commencing  organization. 

And  if  a  still  longer  period  elapses  before  death,  the  organ- 
ization of  the  plastic  lymph  will  be  found  completed,  and  the 
pericardium  will  be  seen  either  firmly  and  uniformly  glued  to 
the  heart,  or  attached  to  it  by  bands,  or  a  net-work  of  fine  ad- 
hesions having  a  smooth  glistening  surface,  and  presenting  the 
characters  of  serous  membrane. 

Such  are  the  eff'ects,  such  the  changes  produced  by  inflamma- 
tion of  the  investing  membrane  of  the  heart,  and  inflammation 
of  its  internal  or  lining  membrane  gives  rise  to  lesions  equally 
striking  and  disastrous.     The  natural  transparency  of  the  mem- 


162  RHEUMATIC   INFLAMMATION    OF    THE    HEART, 

brane  may  be  replaced  by  whiteness  and  opacity ;  fibrin  may 
be  deposited  upon  it,  forming  beaded  or  wart-like  fleshy  excres- 
cences ;  and  lymph  may  be  effused  either  beneath  or  on  its 
surface,  giving  rise  to  thickening,  rigidity,  and  puckering.  In 
some  cases  I  have  known  ulceration  ensue,  which  has  not  only 
produced  a  perforated  condition  of  the  valves,  or  a  broken-down, 
ragged  state  of  their  edges,  but  in  one  or  two  instances,  has 
spread  to  the  chordae  tendineae,  which  have  been  thus  eaten 
through  and  rendered  useless.  Some  cases,  too,  are  on  record, 
though  I  have  never  met  with  one,  in  which  suppuration  of  the 
muscular  substance  of  the  heart  has  taken  place,  and  has  caused 
perforation  of  the  septum  ventriculorum.^  Happily,  however, 
phenomena  such  as  these  are  seldom  the  result  of  rheumatic 
inflammation ;  and  when  they  do  occur,  they  may  be  regarded 
as  the  offspring  of  a  peculiarly  unhealthy  constitution. 

It  sometimes  happens  that  inflammatory  products  are  found 
in  the  different  chambers  of  the  heart,  more  especially  in  the 
left  auricle;  but  in  most  instances  they  are  confined  to  the  val- 
vular apparatus  or  its  immediate  neighborhood,  and  the  mitral 
and  aortic  valves,  the  valves  which  have  most  fibrous  tissue  in 
their  composition,  and  which  are  constantly  bathed  in  highly- 
fibrinized  arterial  blood,  are  those  which  appear  peculiarly  liable 
to  suffer.  The  right  cavities,  however,  with  their  tricuspid  and 
pulmonary  semilunar  valves,  are  sometimes,  though  rarely, 
affected.^ 

The  fibrinous  vegetations  which  constitute  the  most  frequent 
form  of  rheumatic  valvular  lesions  vary  greatly  in  their  appear- 
ances in  different  cases  and  at  difterent  stages  of  their  existence. 
They  are  often  very  numerous,  and  vary  in  size  from  a  pin's 
head  to  a  millet-seed.  They  are  at  one  time  isolated  and  dis- 
tinct from  each  other,  at  another  partially  confluent;  and  when 
several  spring  from  a  common  base,  they  may  form  a  mass  of 

1  For  cases  in  illustration  of  this  fact,  see  Dr.  Watson's  ■•  Practice  of  Physic," 
ed.  I,  vol.  ii,  p.  287,  and  a  Report  by  .Mr.  Avery,  iu  the  second  volume  of  the 
"  Trans,  of  the  Pathological  Society  of  London." 

2  For  cases  in  point,  see  the  fifth  volume  of  the  "Edinburgh  .Medical  and 
Surgical  Journal,"  and  the  particulars  of  a  case  recorded  by  my  colleague,  Dr. 
Wilson,  in  the  "Lancet"  for  1844,  vol.  ii,  p.  217. 


ITS    PATHOLOGICAL    EFFECTS.  163 

considerable  size.  Sometimes,  when  their  growth  has  been 
rapid,  or,  to  speak  more  correctly,  when  fibrinous  accretion  has 
taken  place  rapidly,  as  it  does  under  certain  conditions  of  con- 
stitution, their  form  is  changed,  and  the  action,  which  in  other 
states  of  the  system  might  have  resulted  in  the  deposition  of 
small  warty  granules  along  the  edges  of  contact  of  the  valves, 
gives  rise  to  the  production  of  long  filamentous  growths,  or  of 
large  pedicled  masses  forming  pendulous  tumors,  which  hang 
loosely  into  the  ventricle,  and  are  moved  to  and  fro  by  the  cur- 
rent of  the  blood. ^  When  the  vegetations  assume  the  former 
character,  they  are  usually  confined  to  the  valves,  and  chiefly 
affect  their  edges  of  contact,  so  that  in  the  sigmoid  valves  they 
are  arranged  in  a  double  crescentic  form  f  but  when  their 
growth  is  more  luxuriant,  as  in  the  instances  last  alluded  to, 
they  are  more  widely  distributed  over  the  endocardial  mem- 
brane. The  surface  of  the  valves,  against  which  the  current  of 
the  blood  is  directed,  is  often  thickly  studded  with  them ;  on 
the  edges  of  contact  of  the  valves,  they  form  festoons  or  fringes ; 
the  chordae  tendineae  attached  to  the  mitral  valve  are  sometimes 
loaded  with  an  abundant  crop  of  them;  and  occasionally  in  the 
different  chambers  of  the  heart,  more  especially  in  the  left 
auricle,  they  are  scattered  profusely  over  the  entire  surface  of 
the  lining  membrane.  Judging  from  my  own  experience,  the 
cases  in  which  these  last  forms  of  vegetation  occur  are  just 
those  in  which,  either  from  some  constitutional  peculiarity,  or 
from  some  other  cause  equally  beyond  our  ken,  these  accretions 
manifest  a  strong  tendency  to  decay,  and  in  which  arise  those 
formidable  erosions  and  ulcerations  already  mentioned  as  some- 
times accompanying  rheumatic  endocarditis.* 

The  microscopic  examination  of  these  fibrinous  deposits  es- 

1  Some  of  these  masses,  measuring  from  half  an  inch  to  an  inch  in  length, 
are  preserved  in  the  museum  of  St.  George's  Hospital. 

2  Dr.  Watson's  "Lectures,"  ed.  1,  vol.  ii,  p.  267. 

^  "In  a  patient  of  Dr.  Hawkins's,  I  saw  a  cylindrical  excrescence  of  this 
kind,  which  measured  an  inch  in  length.  The  valves  presented  slit-like  perfo- 
rations, and  from  the  edge  of  one  of  these  slits  in  the  mitral  valve,  this  long 
vegetation  dangled  into  the  ventricle.  The  whole  of  the  valves  of  the  aorta 
were  covered  on  their  ventricular  surface  with  similar  but  shorter  excrescences." 
(Dr.  Watson's  "Lectures,"  ed.  1,  vol.  ii,  p.  25.S.) 


164  KHEUMATIC    INFLAMMATION    OF   THE    HEART, 

tablishes  the  itientity  in  nature  of  their  different  forms,  and 
shows  that  they  are  sometimes  granular,  but  more  generally 
imperfectly  fibrous  in  texture,  presenting  somewhat  of  a  lami- 
nated appearance ;  and  that  throughout  their  structure  are 
numerous  granules  and  granular  masses,  and  oil-globules  in 
varying  proportions.  In  some  instances  of  old-standing  rheu- 
matic endocarditis,  I  have  seen  cartilaginous  and  calcareous 
deposits  on  the  valves  and  in  the  fibrinous  deposits ;  but  this, 
doubtless,  has  resulted  from  earthy  or  atheromatous  degenera- 
tion which  has  taken  place  subsequently  to  the  attack,  in  which 
the  valves  were  injured  or  the  fibrin  first  deposited. 

In  color  and  consistency  these  accretions  vary  just  as  much 
as  in  size  and  in  position.  They  are  sometimes  gray  and 
friable,  sometimes  of  a  pink  or  reddish  color,  soft,  and  easily 
broken  down,  and  can  be  readily  detached  from  the  smooth 
surface  of  the  membrane  on  which  they  are  deposited ;  at 
others,  they  are  less  colored,  and  of  a  much  firmer  consistence, 
but  still  admit  of  being  separated  from  the  membrane  ;  while, 
in  another  class  of  cases,  or  rather  at  a  more  advanced  period 
of  the  disease,  they  become  perfectly  colorless,  and  so  firmly 
adherent,  that  they  can  be  removed  only  by  tearing  the  mem- 
brane to  which  they  are  attached.  At  a  still  later  period,  these 
warty  growths  or  bead-like  accretions  cease,  in  most  cases,  to 
exist  as  such  upon  the  valves  ;  they  become  by  degrees  more 
firmly  agglutinated  to  the  endocardial  membrane,  and  incorpo- 
rated with  the  structure  of  the  valve ;  and  merging  gradually 
into  one  another,  until  the  divisions  between  the  several 
granules  are  efi"aced,  they  are  ultimately  replaced  by  a  lami- 
nated ridge  of  fibrin.  This  is  marked  at  first  by  serratures 
corresponding  to  the  divisions  between  the  original  granules, 
but  after  a  time  it  also  loses  all  traces  of  its  origin  or  mode  of 
formation,  and  becomes  smooth  and  polished  like  the  rest  of  the 
endocardium. 

Such  are  the  changes  which  ensue  when  there  is  a  tendency 
to  the  repair  of  these  valvular  lesions;  but  when,  as  is  fre- 
quently the  case,  there  exists  a  tendency  to  further  disorgani- 
zation, the  changes  which  occur  are  of  a  different  character. 


ITS    PATHOLOGICAL    EFFECTS.  165 

The  fibrinous  deposits  appear  to  excite  unusual  irritation,  and 
to  give  rise  to  thickening  of  the  valves,  with  gradually  induced 
rigidity,  corrugation,  and  contraction  ;  the  motion  of  the  valves 
becomes  more  and  more  limited,  and  adhesion  of  their  flaps 
sometimes  ensues ;  or,  perhaps,  earthy  or  atheromatous  degen- 
eration takes  place,  and  the  valvular  apparatus,  strained  by  the 
unwonted  force  and  frequency  of  the  heart's  action,  and  ren- 
dered weak  and  brittle  by  the  changes  it  has  undergone,  is  no 
longer  able  to  offer  resistance,  and  is  lacerated  or  slit  up. 

These  changes  on  the  internal  surface  of  the  heart,  resulting 
from  acute  rheumatic  inflammation,  are  far  more  serious  than 
those  produced  by  inflammation  of  its  external  surface.  If,  in 
the  first  fury  of  its  attack,  pericarditis  be  as  important  and 
dangerous  as  endocarditis,  it  certainly  is  less  so  in  the  lesions 
it  leaves  behind  it,  and  in  the  consequences  to  which  it  ulti- 
mately gives  rise.  It  has  been  stated  that  when  the  former 
disease  is  extensively  diffused,  effusion  of  lymph  and  serum 
takes  place  which  gives  rise  to  adhesions,  more  or  less  general, 
between  the  visceral  and  parietal  layers  of  the  pericardium. 
The  investing  membrane  becomes  either  partially  or  wholly 
glued  to  the  heart  by  the  interposed  lymph,  or  loosely  attached 
to  it  at  one  or  more  spots  by  a  single  band  or  a  net-work  of 
adhesions.  The  slightest  adhesions  must  certainly  embarrass 
the  heart's  action  to  a  greater  or  less  extent,  yet  when  they  are 
partial  only,  and  take  place  between  such  parts  of  the  pericar- 
dium as  are  naturally  in  apposition,  or  when,  on  the  other 
hand,  they  are  universal,  they  derange  the  heart's  action  far 
less  than  might  be  expected,  I  have  repeatedly,  on  dissection, 
seen  old  lesions  such  as  these  in  persons  who  for  years  before 
their  death  had  been  in  excellent  health,  and  during  life  had 
exhibited  no  symptoms  of  diseased  heart.  But  when  the 
adhesions  are  formed  between  those  portions  of  the  pericardial 
sac  which  are  not  naturally  in  apposition,  then,  unless  they  be 
very  loose,  they  cause  a  drag  upon  the  heart,  and  restrain  the 
freedom  of  its  action  to  a  much  greater  degree  ;^  palpitation  and 

1  Louis  has  recorded  an  instructive  case  in  point.  A  single  adhesion  had 
taken  place  between  the  parietal  pericardium  and  that   portion  of  the  visceral 


166  RHEUMATIC   INFLAMMATION    OP   THE   HEART, 

dyspnoea  ensue,  and  the  organ,  struggling  to  overcome  the 
resistance,  becomes  gradually  more  and  more  dilated  and 
bypertrophied,  until,  when  it  is  unable  any  longer  to  fulfill  its 
functions,  the  blood  begins  to  be  arrested  in  its  passage  through 
the  lungs,  and  cough  and  dyspnoea  and  palpitation  result.  Then 
follows  the  terrible  array  of  symptoms  connected  with  an 
impeded  pulmonary  circulation  :  A  loading  of  the  capillaries 
with  dark-colored,  imperfectly  aerated  blood,  coldness  and 
lividity  of  the  extremities,  blueness  of  the  lips  and  face,  con- 
gestion of  the  liver  and  other  internal  organs,  and,  as  the 
natural  consequence,  dropsical  effusion  into  the  cavities  of  the 
chest,  into  the  abdomen,  and  into  the  cellular  tissue  of  the  body. 
Nor  do  these  fearful  changes  occur  without  producing  a  pro- 
portionate amount  of  suffering.  Excessive  palpitation,  with 
prjBcordial  pain  and  anguish  ;  paroxysms  of  dyspnoea  threat- 
ening suffocation,  orthopnoea,  constant  restlessness,  and  impos- 
sibility of  sleep  ; — these  are  among  the  inevitable  consequences 
of  such  an  embarrassed  state  of  the  vascular  and  respiratory 
systems,  and  are  the  symptoms  immediately  preceding  death. 
Cases^  however,  in  which  symptoms  such  as  these  are  dependent 
solely  on  exocardial  mischief  are  of  rare  occurrence,  inasmuch 
as  extensive  rheumatic  pericarditis  seldom  runs  its  course 
without  concurrent  endocardial  inflammation,  and  even  when  it 
does  so,  rarely  produces  much  hypertrophy  of  the  heart,  or  gives 
rise  to  any  marked  symptoms  of  cardiac  affection,  unless,  as 
already  stated,  the  adhesions  which  result,  whether  partial  or 
universal,  are  formed  between  those  parts  of  the  membrane 
which  are  not  naturally  in  apposition.  Such  at  least  is  the 
result  of  my  experience ;  the  only  exception  being  in  the  case 
of  patients  who,  from  their  position  in  life,  have  been  forced  to 
pursue  some  laborious  occupation.' 

pericardium  which  invests  the  right  ventricle.  The  result  was,  that  the  patient 
was  unable  to  lie  on  his  back,  inasmuch  as,  whenever  he  assumed  that  posi- 
tion, the  heart  at  each  systole  dragged  upon  the  band  which  held  it  back,  and 
thereby  caused  excessive  pain  and  smarting. 

1  I  am  acquainted  with  a  gentleman,  at  the  present  time,  who  had  a  severe 
attack  of  pericarditis,  at  the  age  of  ten,  followed  without  doubt  by  very  general 
adhesion  of  the  pericardium.     He  is  now  twenty-nine  years  of  age,  and  has 


ITS    PATHOLOGICAL    EFFECTS.  167 

But  when  inflammation  of  the  endocardium  has  occurred,  and 
any  permanent  traces  of  its  ravages  have  been  left  behind, 
hypertrophy  and  dilatation  are  almost  certain  to  be  produced 
before  any  lengthened  period  has  elapsed.  In  this  CMse  the 
chief  effects  of  the  inflammation  are  displayed  on  the  valvular 
apparatus  of  the  heart;  and  so  delicate  and  so  nicely  adjusted 
is  this  apparatus,  that  any  damage  it  sustains,  however  slight, 
must  necessarily  interfere  with  the  due  maintenance  of  the 
circulation.  If  the  valves  be  not  actually  broken  down  by 
ulceration,  or  loaded  with  fringes  of  fibrinous  deposits,  they 
will  probably  be  rendered  thicker  and  more  rigid  than  natural, 
or  will  bear  on  their  angles  small  bead-like  or  granular  accre- 
tions. In  order  to  overcome  the  obstacle  thus  presented  to  the 
circulation,  the  heart  will  have  to  contract  more  forcibly  than 
natural.  Thus,  if  the  obstruction  be  permanent,  and  the 
increased  labor  of  the  heart  continue,  hypertrophy  of  its  walls 
and  dilatation  of  its  cavities  will  be  produced,  and  then,  as  in 
the  former  case,  the  disease  will  prove  fatal,  with  palpitation, 
dyspnoea,  and  dropsy.  Of  course,  the  rapidity  with  which  the 
disease  runs  its  course  will  depend,  in  some  measure,  upon  the 
irritability  of  the  heart,  the  state  of  the  lungs,  the  habits  of  the 
patient,  and  other  collateral  circumstances,  but,  eseteris  'paribus, 
it  Avill  bear  a  tolerably  constant  relation  to  the  amount  and 
nature  of  the  valvular  disease.  The  more  serious  the  mischief, 
the  greater  the  obstruction  to  the  blood's  current,  the  quicker 
will  hypertrophy  and  dilatation  result,  and  the  sooner  will  the 
effects  of  these  lesions  be  perceived. 

I  have  hinted  that  the  mischief  produced  by  endocarditis 
may  not  be  of  such  a  nature  as  permanently  to  affect  the  action 

never  yet  experienced  the  slightest  heart  symptoms.  x\s  a  boj',  he  took  violent 
and  protracted  exercise  in  running,  and  his  heart  soon  became  somewhat 
hypertrophied  and  dilated,  though  not  so  as  to  cause  him  any  uneasiness;  but 
from  the  age  of  eighteen  he  has  lived  a  quiet  life,  and  I  cannot  perceive  any 
alteration  in  the  condition  of  the  heart  since  that  time.  Nor  do  I  believe  this 
to  be  a  singular  instance.  Dr.  Wm.  Bndd,  who  has  had  much  experience  in 
these  matters,  reports  that  he  has  "  seen  a  great  number  of  cases  of  adhesion 
of  the  pericardium  (often  general)  of  long  standing,  in  which  the  heart  was  in 
all  other  respects  natural,  and  its  functions  during  life  (almost?)  perfectly 
performed."     "  Library  of  Medicine,"  vol.  v,  p.  195  ) 


168  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

of  the  heart,  and  there  is,  I  think,  presumptive  evidence  to  show 
that  some  thickening  of,  or  deposit  on  the  valves  may  take 
place,  and  may  he  entirely  got  rid  of  by  absorption.  Thus, 
seeing  how  readily  such  lesions  are  repaired  in  other  parts  of 
the  body,  there  can  be  little  doubt  but  that  when  the  results  of 
endocarditis  are  confined  to  redness  and  oedcmatous  swelling, 
the  mischief  may  subside,  and  altogether  disappear,  with  the 
gradual  cessation  of  inflammatory  action.  Even  when  lymph 
has  been  poured  out  on  the  surface  or  in  the  substance  of  the 
valves,  there  is  reason  to  believe  that  it  may  be  gradually  re- 
absorbed, and  the  damage  completely  repaired.  In  most  cases, 
however,  we  should  not  be  justified  in  anticipating  such  a  happy 
result:  experience  has  shown  that  not  unfrequently  the  process 
of  repair  is  imperfectly  effected,  the  valves  remaining  thicker 
and  more  rigid  than  natural.  And  when,  as  sometimes  hap- 
pens, the  valves  are  coated  with  plastic  lymph,  and  become 
more  or  less  agglutinated  together,  or  one  of  them,  perhaps,  is 
folded  on  itself,  and  its  apex  glued  either  to  the  adjoining  sui'- 
face  of  the  aorta  or  to  some  other  portion  of  its  own  area,  then 
the  damage  which  has  been  sustained  is  irreparable,  and  the 
disease  must  tend  rapidly  to  a  fatal  termination. 

But  there  is  another  class  of  cases,  in  which  the  question  of 
the  possibility  and  probability  of  repair  does  not  admit  of  such 
a  certain  answer.  I  allude  to  those  cases  in  which  fibrinous 
deposits,  more  or  less  extensive,  take  place  upon  the  valvular 
apparatus.  In  extreme  instances,  doubtless,  repair  is  impos- 
sible ;  but  presumption  favors  the  belief  that  in  ordinary  cases 
it  is  often  efiected  more  or  less  perfectly.  The  absorption  of 
the  lymph  eifused  in  pericarditis  affords  a  proof  that  the  pro- 
cesses essential  to  repair  may  take  place  in  the  heart  as  in 
other  organs,  and  the  results  observed  to  follow  inflammation 
of  other  fibrous  tissues  are  conclusive  as  to  there  being  nothing 
in  the  structure  of  the  parts  to  prevent  fibrinous  accretions  on 
the  valvular  apparatus,  and  the  thickening  to  which  they  give 
rise,  from  being  in  like  manner  got  rid  of,  and  the  parts  restored 
to  their  former  healthy  condition.  Nay,  more  than  this:  dis- 
section has  shown  that  the  jirocess  of  reparation  does  sometimes 


ITS    SYMPTOMS    AND    PROGRESS.  169 

advance  to  a  considerable  extent-/  and  observation  has  proved 
that  functional  if  not  organic  repair  may,  in  some  instances,  be 
completed.^  But,  practically,  I  fear  the  cases  are  few  in  which 
this  process  can  be  efficiently  carried  out.  When  complete 
reparation  is  effected  in  other  fibrous  structures,  it  is  mainly 
attributable  to  the  perfect  rest  at  which  the  parts  are  kept,  and 
to  the  mechanical  and  other  local  applications  we  are  enabled 
to  make  use  of;  and,  even  in  pericarditis,  the  injured  parts  are 
kept  comparatively  quiet,  by  the  adhesion  of  the  two  opposed 
layers  of  the  inflamed  membrane ;  the  irritated  surface  of  the 
membrane  can  be  no  longer  subjected  to  attrition ;  no  more 
lymph  or  serum  can  be  poured  out,  and  that  which  has  been 
already  effused  may,  to  a  great  extent,  be  got  rid  of  by  absorp- 
tion. But  the  mischief  about  the  valves  takes  place  under  dif- 
ferent circumstances,  and  is  altogether  of  a  different  nature. 
The  fibrinous  vegetations  which  are  frequent  concomitants  of 
rheumatic  endocarditis,  and  are  the  lesions  from  which  injury 
most  frequently  results,  are  not  the  products  of  inflammatory 
exudation,  but  are  deposited  from  the  blood,  and  may  and  do 
occur  not  only  during  active  inflammation,  but  during  a  state 
of  mere  irritation.^  Hence,  as  the  constant  motion  of  the 
valves  must  tend  to  keep  up  such  a  condition,  and,  as  the  irri- 
tability must  be  further  excited  by  the  existence  of  these 
adventitious  deposits,  I  fear  there  is  little  chance  of  recovery 
when  obstruction  to  the  circulation  is  dependent  upon  this  form 
of  lesion.  Accurate  observation,  however,  and  sound  deduction, 
point  out  the  possibility  of  such  a  favorable  issue,  though  ex- 
perience scarcely  holds  out  any  prospect  of  its  occurrence.  On 
three  several  occasions  I  have  had  reason  to  believe  that  their 
removal  has  been  effected  partially,  if  not  wholly.  In  the 
instances  alluded  to,  the  accession  of  heart  disease  was  marked 

^  Aniea,  p.  164. 

"  For  some  excellent  remarks  oa  this  subject,  see  Dr.  Orraerod's  "  Gulstonian 
Lectures.'' 

'  This  was  beautifully  exemplified  in  the  course  of  Dr.  Hope's  experiments 
on  the  ass.  As  the  circulation  became  sluggish,  a  deposition  of  fibrin  forming 
a  fleshy  vegetation  took  place  at  the  spot  where  the  heart's  valves  had  beea 
irritated. 

12 


170  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

Ly  all  the  general  and  physical  signs  of  endocarditis,  and  the 
valvular  murmur  was  most  intense.  Nevertheless,  on  the  rapid 
subsidence  of  inflammation,  the  bellows-murmur  gradually 
ceased.  In  two  of  these  cases  the  sound  commenced  so  sud- 
denly, increased  so  rapidly,  and  was  accompanied  by  such 
well-marked  general  and  local  symptoms  of  carditis,  that  there 
could  be  no  more  doubt  as  to  the  occurrence  of  inflammation, 
and  of  some  deposit  or  thickening  as  the  result  of  that  inflam- 
mation, than  would  attach  to  any  fact  announced  through  the 
stethoscope,  but  not  submitted  to  ocular  demonstration.  Doubt- 
less the  murmur  in  each  of  these  instances  is  explicable,  on  the 
supposition  that  the  valves  were  merely  inflamed  and  swollen, 
or  that  lymph  had  been  eff'used  on  their  surface ;  but  so  con- 
stantly are  fibrinous  deposits  associated  with  rheumatic  endo- 
cardial inflammation,  that  the  existence  of  such  deposits  in  the 
cases  alluded  to  is  rendered  extremely  probable.^ 

Without  pausing  to  enter  more  fully  into  details  respecting 
the  changes  induced  by  endocarditis,  I  will  at  once  pass  on  to 
the  next  part  of  the  subject,  and  will  endeavor  to  point  out  the 
natural  connection  subsisting  between  the  structural  altera- 
tions caused  by  exocardial  and  endocardial  inflammation,  and 
the  various  physical  signs  by  which,  during  life,  we  are  able  to 

1  Three  other  sources  of  this  adventitious  valvular  sound  might  be  sug- 
gestpd:  Istly,  the  an;emic  condition  of  the  patient;  2dlj,  the  increased  force 
of  the  heart's  action,  corabineil  with  some  disproportion  between  the  size  of 
its  cavities  and  the  orifices  of  the  aorta  or  pulmonary  artery;  3dly,  the  irre- 
gular contraction  of  the  structures  connected  with  the  valvular  apparatus, 
consequent  on  the  morbidly  exciting  condition  of  the  blood.  Neither  of  these 
explanations,  however,  seems  applicable  to  the  murmur,  in  the  cases  in  ques- 
tion. For,  in  the  first  place,  the  patients  had  not  been  subjected  to  depletion, 
neither  were  they  ana-mic,  nor  was  the  sound  heard  in  the  course  of  the  large 
vessels,  as  on  such  a  supposition  it  ought  to  have  been ;  2dly,  there  was  no 
evidence  of  any  disproportion  between  the  size  of  the  ventricles  and  the  orifices 
of  the  great  vessels,  and  even  if  there  had  been,  a  murmur  consequent  thereon 
should  have  arisen  at  an  earlier  period  of  the  attack,  when  the  heart  was  act- 
ing quite  as  rapidly  and  forcibly ;  and,  3dly,  had  it  been  due  to  irregular  con- 
traction of  the  structures  connected  with  the  valves,  and  not  to  organic 
mischief  occurring  in  the  valves  themselves,  it  should  have  evinced  some 
irregularit3',  both  as  to  its  character  and  continuance,  whereas  it  remained 
constant,  and  of  the  same  character  throughout,  though  increasing  steadily  in 
intensity. 


ITS    SYMPTOMS    AND    PROGRESS.  171 

detect  their  existence,  and  to  trace  the  various  steps  in  their 
progress.  Here,  again,  to  facilitate  explanation,  I  will  first 
suppose  inflammation  of  the  investing  membrane  of  the  heart 
to  take  place,  Avithout  the  concurrence  of  the  endocardial  mis- 
chief, and  will  then  trace  the  course  of  an  attack  of  endo- 
carditis occurring  independently  of  pericardial  inflammation. 

Before  tliis,  however,  let  us  briefly  consider  the  condition 
of  the  parts  in  a  state  of  health.  Closely  applied  to  and 
investing  the  heart  is  a  membrane,  which,  on  reaching  the 
root  of  the  large  vessels,  is  reflected  on  itself  and  forms  a  close 
sac.  This  sac  is  termed  the  pericardium.  On  its  internal 
surface  it  is  lined  by  a  smooth  and  glistening  serous  membrane, 
the  two  layers  of  which,  in  their  natural  state,  glide  smoothly 
and  noiselessly  over  each  other,  at  each  successive  systole  and 
diastole  of  the  heart.  But,  in  disease,  the  condition  of  the 
parts  is  changed,  and  their  mechanism  altered.  As  soon  as 
the  sac  becomes  inflamed,  and  pericarditis,  as  it  is  termed,  sets 
in,  the  smooth  and  glistening  membrane  becomes  dry,  and, 
after  a  time,  covered  by  a  rough  irregular  coating  of  efl'used 
lymph;  its  lubricity  is  consequently  destroyed,  and  its  motion, 
which  before  was  noiseless,  is  accompanied  by  the  sound  of 
friction,  occasioned  by  the  attrition  of  the  two  opposed  and  dry 
or  roughened  surfaces.  And  a  very  peculiar  sound  this 
rubbing  sound  is.  Sometimes  it  is  rough,  harsh,  and  rasping  ; 
sometimes  it  more  nearly  resembles  the  creaking  of  leather,  as 
it  is  heard  in  a  new  saddle  in  riding ;  but  whatever  its  tone  or 
musical  variety,  it  has  the  peculiarity  of  being  almost  invaria- 
bly a  to-and-fro  sound,  accompanying  the  whole  of  the  heart's 
action,  and  superadded  to  its  natural  sound. ^  From  the  posi- 
tion of  the  parts  in  which  it  takes  its  origin,  this  sound  is 
superficial,  and  seems  near  to  the  ear,  and  this,  among  other 

1  This  peculiarity  of  the  sound  attendant  upon  pericardial  inflammation  was 
first,  I  believe,  pointed  out  by  Dr.  Watson,  and  about  the  same  time,  by  Dr. 
Stokes,  of  Dublin.  To  these  eminent  physicians  the  profession  is  indebted  for 
the  separation  or  analysis  of  the  abnormal  sounds,  arising  in  the  course  of 
cardiac  inflammation:  in  other  words,  for  distinguishing  between  the  friction- 
sound  and  the  bellows-murmur,  and  for  showing  that  the  former  results  from 
exocardial  inflammation,  the  latter  from  causes  connected  with  the  internal 
surface  of  the  heart. 


172  RHEUMATIC    INFLAMMATION    OF    THE    HEAKT, 

things,  serves  to  distinguisli  it  from  the  double  bellows-murmur, 
which  is  pathognomonic  of  valvular  disease.  Another  peculiarity 
attaches  to  this  sound.  Unlike  the  double  murmur  of  valvular 
disease,  which  generally  arises  from  permanent  mischief,  and 
is  therefore  necessarily  persistent,  the  to-and-fro  sound  of 
pericardial  friction  results  from  causes  of  a  transient  nature, 
and  endures,  therefore,  only  for  a  limited  period.  It  arises,  as 
already  shown,  from  the  rubbing  of  the  two  roughened  layers 
of  the  pericardium,  and  anything  Avhich  prevents  this  rubbing 
must  necessarily  put  a  stop  to  the  friction-sound  also.  Hence 
it  may  cease  from  one  of  two  causes  :  either  from  adhesion  of 
the  two  layers  of  the  membrane  by  means  of  interposed  lymph, 
or  from  their  total  separation  by  the  effusion  of  a  large 
quantity  of  serum.  In  the  former  case,  the  cause  of  its  cessa- 
tion is  a  permanent  one  ;  consequently,  when  adhesion  is  firm 
and  universal,  the  friction-sound  can  never  recur  ;  in  the  latter, 
its  cessation  is  due  to  temporary  causes  only,  and  when  the 
serum  is  reabsorbed,  and  the  inflamed  and  roughened  surfaces 
come  again  into  apposition,  the  sound  of  attrition  will  probably 
reappear,  to  cease  only  when  permanent  adhesion  has  taken 
place.  So  that  in  watching  a  case  of  pericarditis,  we  must  not 
be  misled  by  the  subsidence  of  the  friction-sound.  If  we  have 
once  satisfied  ourselves  as  to  its  existence,  we  must  endeavor 
to  ascertain  whether  its  disappearance  be  due  to  excessive 
effusion,  or  to  adhesion  of  the  two  layers  of  the  membrane  ;  as 
if  due  to  the  former  cause,  it  would  be  a  fatal  mistake  to 
slacken  in  our  efforts  to  arrest  the  disease,  under  the  idea  that 
adhesion  had  taken  place,  and  that  the  disease  was  progressing 
to  a  favorable  termination.  Fortunately,  therefore,  the 
effusion  to  which  I  have  alluded  gives  abundant  physical  signs 
of  its  existence. 

The  first  and  natural  effect  of  its  occurrence,  is  the  produc- 
tion of  a  dull  sound  on  percussion  in  the  praecordial  re- 
gion. In  the  normal  condition  the  precordial  dullness  is 
seldom  above  an  inch  and  a  half  or  two  square  inches  in  extent, 
as  the  lung  laps  over  the  remainder  of  the  heart,  and  yields  a 
clear  sound  on  percussion.     But  when  effusion  takes  place  into 


ITS    SYMPTOMS    AND    PROGRESS.  173 

the  pericardial  sac,  the  space  occupied  by  the  heart  and  its 
envelope  increases,  the  lungs  are  pushed  aside,  and  the  chest 
is  found  to  yield  a  dull  sound  on  percussion,  where  it  had  pre- 
viously furnished  a  well-marked  resonance.  Sometimes  this 
dullness  is  found  as  high  as  the  second  or  even  the  first  left 
rib ;  sometimes  it  extends  beneath  the  whole  length  of  the 
sternum,  except  about  an  inch  and  a  half  at  the  top  ;  not 
unfrequently  it  reaches  over  to  the  right  side  of  the  sternum, 
and  occasionally  I  have  known  it  to  extend  over  almost  the 
whole  of  the  anterior  surface  of  the  chest.  Sometimes,  indeed, 
increased  pr?ecordial  dullness  may  be  occasioned  by  old-stand- 
ing enlargement  of  the  heart ;  but  in  a  previously  healthy 
person  it  is  symptomatic  of  effusion,  and  affords  a  tolerably 
accurate  measure  of  its  amount.  Its  absence,  however,  must 
not  be  regarded  as  certainly  indicative  of  the  absence  of 
effusion,  as  the  dullness  which  otherwise  would  have  resulted 
from  the  presence  of  effusion,  may  be  masked  by  the  interven- 
tion of  a  portion  of  emphysematous  lung.  In  such  a  case  the 
chest  would  yield  unusual  resonance. 

Thus,  then,  if  the  cessation  of  the  friction-sound  be  dependent 
on  distention  of  the  pericardial  sac,  percussion  will  readily 
indicate  the  fact;  and  in  proportion  as  the  effusion  increases 
in  quantity,  so  will  the  limits  of  the  dullness  be  extended,  and 
so  also  will  the  heart's  action  become  more  and  more  embar- 
rassed, its  impulse  more  feeble  and  irregular,  and  its  sounds 
more  distant  and  less  audible.  This,  I  need  hardly  say,  is  just 
the  reverse  of  what  happens  when  the  friction-sound  ceases  in 
consequence  of  adhesion  of  the  two  layers  of  membrane;  for  as 
absorption  progresses,  and  adhesion  takes  place,  the  prsccordial 
dullness  decreases  in  extent,  the  heart's  impulse  becomes 
steadier,  its  sounds  louder  and  clearer,  and  the  pulse  firmer 
and  more  regular. 

It  may  sometimes  happen,  that  we  miss  listening  to  the 
heart  until  so  much  fluid  has  been  effused  into  the  pericardium 
that  a  friction-sound  is  no  longer  audible.  In  hospital  practice 
patients  often  are  not  seen  until  after  the  stage  of  attrition  lias 
passed  away ;  and  even  in  private  practice   cases  sometimes 


174  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

occur,  in  -v\hicli,  either  from  the  rapidity  with  Avhich  effusion 
has  taken  phice,  or  from  tlie  absence  of  pain  and  other  general 
symptoms  of  cardiac  distress,  the  stage  of  attrition  is  entirely 
overlooked.  In  some  such  instances  an  inclination  of  the  body 
forward,  or  firm  pressure  exerted  over  the  region  of  the  heart, 
serves  to  bring  the  two  layers  of  the  pericardium  into  apposi- 
tion, and  thus  enables  us  to  detect  exocardial  friction.  But  it 
sometimes  happens  that  even  these  measures  are  ineffectual, 
and  then  percussion  is  peculiarly  valuable  ;  it  affords  informa- 
tion not  otherwise  attainable.  I  have  known  prsecordial  dull- 
ness, for  days,  the  only  physical  sign  of  the  mischief  Avhich  had 
occurred,  and  taken  conjointly  with  the  distance,  feebleness, 
and  irregularity  of  the  heart's  sounds,  it  has  enabled  me  to 
trace  accurately  the  extent  to  which  effusion  had  proceeded. 

There  is  one  other  physical  sign  by  which  the  existence  of 
pericarditis  is  sometimes  marked.  •  I  mean  a  peculiar  fremisse- 
ment  or  thrill  communicated  to  the  chest,  and  from  the  chest 
to  the  hand,  when  placed  on  the  situation  of  the  heart.  This 
strange  sensation  is  most  perceptible  between  the  cartilages  of 
the  second  and  third,  and  the  third  and  fourth  ribs  on  the  left 
side  of  the  chest.  Like  the  friction-sound,  it  results  from  a 
vibration  occasioned  by  the  attrition  of  the  two  roughened 
surfaces  of  the  pericardium,  and  hence  it  imparts  to  the  touch 
the  same  information  Avhich  is  conveyed  by  the  friction-sound 
to  the  ear.  Its  appearance  and  its  disappearance  are  also 
regulated  by  the  same  circumstances  on  which  the  commence- 
ment and  the  cessation  of  the  friction-sound  depend,  but,  unlike 
the  friction-sound,  it  is  by  no  means  always,  or  indeed  gen- 
erally, present.  In  every  case  accompanied  by  this  thrill,  in 
which  I  have  had  an  opportunity  of  examining  the  conditions 
of  the  parts  after  death,  the  outer  layer  of  the  pericardium  has 
been  found  glued,  as  it  Avere,  to  the  parietes  of  the  chest  by 
lymph  effused  into  the  anterior  mediastinum  ;  and  if,  as  I 
believe,  this  consolidation  of  the  parts,  and  the  consequent 
formation  of  a  good  conducting  medium,  be  essential  in  peri- 
carditis to  the  production  of  this  tremor,  then  is  the  unfre- 
quency  of  its  occurrence  at  once  explained ;  as  is  also  the  fact, 


ITS    SYMPTOMS   AND    PROGRESS.  175 

that  it  usually  accompanies  the  whole  of  the  heart's  action, 
whereas  the  purring  tremor,  communicated  to  the  chest  by 
extensive  disease  of  the  valvular  apparatus,  is  usually  felt  only 
with  the  systole  of  the  heart,  when  that  organ  is  brought  into 
contact  with  the  anterior  parietes  of  the  chest,  I  do  not 
recollect  having  ever  met  with  this  observation  in  books,  but  I 
have  already  verified  it  in  five  instances,  and  am  satisfied  of  its 
correctness. 

Accompanying  this  thrill,  in  certain  cases,  is  an  undulatory 
movement  visible  on  the  chest,  in  the  same  position  where  the 
friction-thrill  is  felt,  viz.,  between  the  cartilages  of  the  second 
and  third,  and  the  third  and  fourth  left  ribs.  Whenever  the 
eye  detects  this  motion,  it  is  almost  certain  that  the  friction- 
thrill  will  be  sensible  to  the  touch  ;  but  it  by  no  means  follows, 
that  when  friction  can  be  felt,  this  undulatory  movement  will 
be  perceptible  on  the  chest.  This,  I  believe,  is  attributable 
solely  to  the  difference  in  the  amount  and  character  of  the 
effusion.  For  as  the  undulation  is  a  motion  communicated  to 
the  parietes  of  the  chest,  by  the  movement  of  fluid  in  the  peri- 
cardial sac,  it  obviously  will  not,  and  indeed  cannot,  be  present, 
when  the  products  of  inflammation  are  chiefly  solid.  The 
value  of  these  signs,  however,  both  of  friction  and  of  undula- 
tion, is  greatly  diminished  by  the  fact,  that  they  do  not  occur 
until  an  advanced  period  of  the  attack,  when  the  real  character 
of  the  disease  can  hardly  be  mistaken. 

Thus,  then,  the  first  and  the  only  pathognomonic  sign  of  pevi- 
carditis,  is  the  peculiar  sound  of  friction  I  have  endeavored  to 
describe ;  superficial  in  its  situation ;  audible,  perhaps,  over  a 
considerable  surface  of  the  chest,  but  inaudible  along  the  aorta 
or  large  vessels ;  varjung  in  its  tone  according  to  the  nature 
and  amount  of  the  eff"usion,  but  almost  always  preserving  its 
distinctive  character  of  a  to-and-fro  sound,  produced  by  the 
rubbing  of  two  roughened  surfaces  upon  each  other.  In  any 
case  in  which  this  has  once  been  heard,  there  cannot  be  a  doubt 
as  to  the  existence  of  pericardiac  inflammation ;  the  only  ques- 
tion which  can  arise,  is  as  to  its  progress  and  mode  of  termina- 
tion.    And  here  again  we  derive  the  greatest  assistance  from 


17G  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

a  careful  study  of  the  physical  signs.  If  the  friction-sound 
cease  after  a  short  existence,  and  coincident  with  its  cessation 
■we  find  decreasing  dullness  in  the  praecordial  region,  increasing 
steadiness  in  the  heart's  action,  and  clearness  and  loudness  of 
its  sounds,  the  prognosis  must  be  favorable,  inasmuch  as  it  is 
evident  that  adhesion  is  taking  place,  and  that,  unless  some 
unforeseen  accident  occur,  the  patient  will  go  on  rapidly  to 
recovery.  If  the  friction-sound  continue  for  a  considerable 
time,  it  is  evident  that  no  great  amount  of  serum  can  be  present, 
and  that  the  effused  lymph  must  be  of  low  vitality,  with  but 
little  disposition  to  form  adhesions.  Therefore,  although  the 
case  may  go  on  slowly  to  recovery,  its  termination  is  doubtful, 
and  our  prognosis  should  be  given  accordingly.  If,  again,  the 
friction-sound  disappears  at  an  early  period  of  the  attack,  and 
at  the  same  time  we  discover  increasing  dullness  in  the  cardiac 
region,  and  find  the  heart's  impulse  becoming  gradually  weaker 
and  more  irregular,  its  sound  more  feeble  and  distant,  and  the 
pulse  fluctuating  or  intermittent,  then  we  are  made  aware  that 
the  cessation  of  the  sound  is  referable  to  extensive  effusion  into 
the  sac  of  the  pericardium,  whereby  the  heart  is  greatly  em- 
barrassed ;  and  as  this  is  always  an  unfavorable  symptom,  our 
opinion  must  be  very  guarded.  But  even  then,  if,  as  we  watch 
the  case  from  day  to  day,  we  find  these  symptoms  again  de- 
creasing, and  the  friction-sound  gradually  returning,  we  may 
feel  assured  that  absorption  is  taking  place,  and  may  venture 
to  speak  hopefully  of  the  issue,  even  though  the  patient  be 
much  exhausted  and  reduced. 

It  must  be  admitted,  then,  that  the  physical  signs  of  peri- 
carditis are  satisfactory,  not  only  as  resulting  from  evident 
mechanical  causes,  but  as  being  remarkably  distinctive  in  their 
character,  and  enabling  us  to  detect  the  first  commencement  of 
disease.  In  some,  though  by  no  means  in  all  respects,  the  signs 
of  endocarditis  are  equally  satisfactory.  If  we  know  the  pre- 
vious condition  of  the  heart,  they  enable  us  to  discover,  at  an 
early  period,  the  inroad  of  endocardial  inflammation,  and  to 
point  out  with  certainty  the  exact  situation  where  mischief  has 
occurred,  and  where  it  is  still  occurring.     Some  difliculty,  how- 


ITS    SYMPTOMS   AND    PllOGRESS.  177 

ever,  may  arise  in  discriminating  between  those  murmurs  which 
are  referable  to  organic  valvular  mischief,  and  those  which  take 
their  orisrin  in  functional  disturbance ;  and  if  we  are  unac- 
quainted  with  the  previous  condition  of  the  heart,  it  is  sometimes 
almost  impossible  to  say  whether  a  murmur  results  from  exist- 
ing endocardial  inflammation,  or  from  old-standing  valvular 
disease.  Unfortunately,  too,  the  accuracy  of  the  information 
we  derive  from  them  affords  greater  evidence  of  our  skill  in 
diagnosis  than  it  does  of  our  ability  in  effecting  a  cure.  For 
although  they  often  give  us  correct  and  early  intelligence  of 
the  inflammatory  attack,  and  indicate  the  exact  spot  at  which 
mischief  is  taking  place,  we  generally  prove  unsuccessful  in 
arresting  its  progress  until  it  has  produced  some  permanent 
lesions.  They  enable  us  to  hasten  to  our  patient's  rescue,  and 
prevent  the  further  inroads  of  disease,  but  they  too  often  prove 
us  incapable  of  repairing  the  mischief  it  has  already  occasioned. 
The  nature  of  the  lesions  has  been  already  pointed  out. 
They  generally  consist  of  greater  or  less  derangement  of  the 
valvular  apparatus ;  and  chiefly,  though  not  invariably,  affect 
the  valves  on  the  left  side  of  the  heart.  There  may  be  either 
thickening,  or  puckering,  or  rigidity  of  the  valves  themselves, 
or  fibrinous  deposits  on  their  edges  or  surface,  or  perforation, 
or  tearing,  or  breaking  down  of  their  substance.  In  all  these 
cases  the  current  of  the  blood  must  be  more  or  less  interfered 
with ;  in  some  the  onward  current  must  be  obstructed ;  in  some 
a  reflux  of  blood  must  take  place  through  the  imperfectly  closed 
opening;  and  in  others,  the  same  lesion  may  cause  obstruction 
to  the  onward  current,  and  also  permit  of  regurgitation.  In  all, 
however,  an  eddy  must  be  produced,  together  with  a  greater 
or  less  decree  of  vibration  ;  and  the  result  of  such  vibration  is 
the  production  of  a  sound,  or,  as  it -is  often  called,  a  murmur, 
accompanying  the  rhythm  of  the  heart.  If,  when  there  is  much 
obstruction,  the  heart's  cavities  be  enlarged,  and  its  muscular 
walls  strong,  so  that  a  large  current  of  blood  is  driven  forcibly 
past  the  obstruction,  the  murmur  produced  is  more  intense  than 
it  would  be  if  the  cavity  of  the  ventricles  were  not  dilated,  and 


178  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

its  walls  not  thickenetr — than  it  would  be  if  a  much  smaller 
amount  of  blood  were  to  be  driven  less  forcibly  past  the  same 
obstruction ;  and  so  with  every  variety  of  lesion.  The  character 
of  the  sound  itself,  as  well  as  its  intensity,  must  obviously  vary 
according  to  the  exact  nature  of  the  mischief  and  the  relative 
power  and  proportion  of  the  obstructing  and  the  propelling 
forces.  Sometimes  the  sound  has  been  supposed  to  resemble 
the  noise  produced  by  rasping  or  sawing,  and  in  some  cases  it 
has  been  thought  like  the  cooing  of  a  pigeon ;  but  generally  it 
is  suggestive  of  the  blowing  of  a  pair  of  bellows,  and  hence  the 
sound  produced  by  valvular  disease,  whatever  its  character  or 
musical  intonation,  is  usually  known  by  the  title  of  "a  bellows- 
murmur." 

By  the  commencement  of  a  bellows-sound,  then,  we  are  ap- 
prised of  the  access  of  endocardial  inflammation ;  and  by  the 
position  of  the  sound,  by  the  direction  in  which  it  is  heard,  by 
the  time  at  which  it  occurs,  and  by  the  state  of  the  pulse,  we 
are  enabled  to  judge,  with  amazing  accuracy,  of  the  site  of  the 
lesion  from  which  it  originates.  If  the  murmur  be  synchronous 
with  the  systole  of  the  heart,  it  must  obviously  accompany  the 
egress  of  h\ood  frojn  the  ventricle,  and  therefore  must  be  refera- 
ble either  to  obstruction  at  the  aortic  orifice,  or  to  regurgitation 
through  the  mitral  valve. ^  If  it  be  contemporaneous  with  the 
diastole  of  the  heart,  it  must  accompany  the  entrance  of  blood 
into  the  ventricle,  and  therefore  must  be  due  either  to  obstruc- 
tion at  the  mitral  orifice,  or  to  regurgitation  throujih  the  aortic 
outlet.     But  then  comes  the  question  as  to  the  means  of  dis- 

1  Of  course,  if  there  be  great  hypertrophy,  the  thickness  of  the  muscular 
structure  of  the  heart  serves,  in  some  measure,  to  deaden  the  intensity  of  the 
murmur,  as  audible  by  means  of  the  stethoscope. 

2  In  this  instance,  and  indeed  throughout.  I  have  referred  to  valvular  dis- 
ease on  the  left  side  of  the  heart  only,  as  rheumatic  affection  of  the  valves  of 
the  right  cavities  is  exceedingly  rare,  and  its  diagnosis  somewhat  uncertain. 
Should  it  occur,  however,  it  may  be  generally  recognized  by  the  fact  that  the 
tricuspid  murmur  is  heard  further  to  the  right  than  the  corresponding  mitral 
murmur,  and  that  disease  of  the  pulmonary  semilunar  valves  occasions  a  mur- 
mur which  is  more  superficial  in  its  character  than  a  corresponding  aortic 
murmur,  and  is  audible  along  the  track  of  the  pulmonary  artery,  instead  of 
along  the  course  of  the  aorta  and  large  vessels. 


ITS    SYMPTOMS    AND    PROGRESS.  179 

tinguishing  the  two  systolic  murmurs  from  one  another,  and  of 
discriminating;  between  the  two  diastolic  murmurs.  How  can 
we  refer  each  to  its  own  particular  valve  ?  Partly,  as  already 
stated,  by  its  position,  partly  by  the  direction  in  which  it  is 
heard,  and  partly  by  the  character  of  the  arterial  pulse.  If  a 
murmur  accompanying  the  systole  of  the  heart  be  heard  more 
distinctly  at  the  base  of  that  organ,  and  along  the  track  of  the 
aorta,  than  it  is  toward  the  apex  of  the  heart,  then  is  it  due, 
in  all  probability,  to  a  vibration  caused  in  the  onward  current 
of  the  blood  by  obstruction  at  the  aortic  outlet  of  the  ventricle; 
and  this  is  rendered  still  more  probable  if  the  pulse  at  the  wrist 
be  weak.  If,  as  I  have  several  times  had  occasion  to  observe, 
more  especially  in  cases  of  old-standing  rheumatic  disease  of 
the  heart,  the  murmur  be  heard  along  the  track  of  all  the  larger 
vessels;  if  it  be  perceptible  in  the  carotids,  and,  as  it  sometimes 
is,  in  the  wrist ;  and  if  accompanying  this  murmur  a  thrill  be 
felt,  not  only  over  the  region  of  the  heart,  but  even  in  the 
radial  artery,  there  cannot  any  longer  be  a  doubt  on  the  subject, 
as  obstruction  in  the  course  of  the  arterial  circulation  could 
alone  give  rise  to  such  phenomena.  If,  on  the  other  hand,  the 
murmur  be  heard  at  the  apex  and  to  the  left  of  the  heart  more 
distinctly  than  at  the  base  of  that  organ ;  and  if,  accompanying 
this  systolic  murmur,  there  be  irregularity  in  the  arterial  pulse, 
and  great  inequality  in  its  force  and  fullness,  then  is  the  disease 
situated  at  the  mitral  orifice.  In  this  case,  as  in  the  last,  the 
murmur  is  produced  by  the  passage  of  the  blood  through  the 
roughened,  or  the  rigid  and  contracted  valvular  opening,  and 
the  pulse  is  rendered  irregular  and  unequal  by  the  constant 
variation  in  the  quantity  of  the  blood  which,  at  each  contraction 
of  the  ventricle,  regurgitates,  or  makes  its  way  back  through 
the  imperfect  valves  into  the  left  auricle.  And  as  in  the  last 
case,  so  also  in  this,  a  vibration  is  often  communicated  to  the 
chest,  causing  a  thrill  or  purring  tremor  distinctly  perceptible 
to  the  touch ;  a  thrill,  however,  which,  unlike  that  which  occurs 
when  there  is  obstructive  disease  of  the  aortic  valves,  is  occa- 
sioned by  a  backward,  instead  of  by  an  onward  current  of 


180  RHEUMATfC   INFLAMMATION    OF   THE    HEART, 

blood,  and  consequently  is  not  transmitted  to  any  extent  along 
the  aorta  and  the  various  arterial  tubes. 

The  diagnosis  then  between  the  two  systolic  murmurs  is  clear 
and  satisfactory,  and  that  between  the  two  diastolic  murmurs 
is  equally  simple  and  conclusive.  If,  which  is  not  very  fre- 
quently the  case,  the  mitral  valve  be  so  diseased  as  to  cause 
sonorous  vibration  in  the  blood  passing  from  the  left  auricle  to 
the  left  ventricle,  then  will  the  murmur  be  heard  most  dis- 
tinctly about  the  middle  of  the  sternum,  and  thence  toward 
the  apex  of  the  heart ;  the  pulse,  owing  to  the  obstruction,  will 
be  small,  and,  unless  either  the  quantity  of  blood  ejected  at 
each  systole  of  the  heart  be  insufficient  to  cause  the  aortic 
valves  to  flap  distinctly,  or  their  sound  be  drowned  by  the 
adventitious  murmur,  the  natural  short  smart  clack,  occasioned 
by  their  sudden  tension,  will  be  heard  superadded  to  or 
accompanying  the  murmur. 

But  if  the  abnormal  sound  arises  from  the  reflux  of  blood 
through  defective  aortic  valves,  the  signs  produced  will  be  very 
difi'erent.  Not  only  will  the  sound  be  loudest  from  about  the 
middle  of  the  sternum  upward  toward  the  base,  instead  of 
downward  toward  the  apex,  of  the  heart,  but  in  lieu  of  being 
heard  together  with  the  natural  second  sound,  it  will  almost  or 
entirely  replace  it.  Moreover,  it  will  be  heard  along  the  course 
of  the  aorta,  and  all  the  large  arterial  trunks,  and  will  be 
accompanied  by  a  most  singular  and  characteristic  pulse.  This, 
the  pulse  of  aortic  regurgitation,  derives  its  peculiarity  from 
mechanical  causes.  It  is  not  the  weak  pulse  of  aortic  obstruc- 
tion, nor  the  small  pulse  of  mitral  obstruction,  nor  the  unequal 
and  irregular  pulse  of  mitral  regurgitation,  but  in  its  most 
marked  and  most  striking  form,  it  is  the  unsustained  pulse  of 
unobstructed  arteries.  There  is,  in  this  case,  no  impediment 
to  the  onward  current  of  the  circulation,  no  lack  of  blood  to  fill 
the  vessels,  and  no  deficiency  of  power  to  propel  it,  but  from 
the  imperfection  of  the  aortic  valves,  and  the  consequent  reflux 
of  blood  into  the  ventricle,  the  prolonged  swell,  which,  at  each 
systole  of  the  heart,  is  naturally  imparted  to  the  blood  in  the 
vessels,  is  not  sustained ;  the  successive  waves  are,  therefore, 


ITS    SYMPTOMS    AND    PROGRESS.  181 

short  and  abrupt,  and  hence  the  pulse  is  jerking,  and  gives  a 
sensation  as  if  successive  balls  of  blood  were  being  shot  sud- 
denly under  the  finger.  So  strong  is  this  reflux,  and  so  strong 
the  jerking  to  which  it  gives  rise,  when  it  exists  in  any  marked 
degree,  that  the  motion  occasioned  by  it  may  be  seen  even  at 
the  wrist,  and  may  be  felt  in  almost  any  part  of  the  body.^ 

The  lesions  then  produced  by  rheumatic  affections  of  the 
heart,  when  existing  in  a  well-marked  and  uncomplicated  form, 
admit  of  easy  diagnosis,  and  may  soon  be  recognized,  even  by 
an  unpracticed  ear.  But  they  are  often  found  more  or  less 
commingled,  two  or  more  of  them  occurring  in  the  same  case, 
and  thus  their  diagnosis  may  be  greatly  complicated.  The 
pericardium  may  be  inflamed  coincidently  with  inflammation  of 
the  mitral  valve,  and  then  a  deep-seated  systolic  bellows-mur- 
mur, resulting  from  mitral  disease,  may  be  heard  at  the  same 
time  that  the  ear  is  assailed  by  the  loud  superficial  to-and-fro 
sound  of  friction.  Sometimes  there  is  a  double  bellows-murmur, 
the  one  accompanying  the  systole,  and  the  other  the  diastole  of 
the  heart,  and  this  may  be  occasioned  either  by  disease  of  a 
single  valve,  or  by  disease  of  two  separate  valves ;  either  by 
disease  of  a  single  valve,  of  such  a  nature  as  both  to  cause 
obstruction  and  admit  of  regurgitation,  or  of  two  separate 
valves,  the  one  giving  rise  to  the  obstructive,  the  other  to  the 
regurgitant  murmur.  Thus,  not  unfrequently  a  loud  systolic 
aortic  murmur  coexists  with  an  aortic  diastolic  murmur,  and 
occasionally  a  systolic  mitral  murmur  occurs  coincidently  with 
an  aortic  diastolic  murmur.  Sometimes  there  is  even  a  greater 
complication,  and  a  systolic  murmur,  arising  in  part  from  mitral 
regurgitation,  in  part  from  aortic  obstruction,  is  followed  by  a 
diastolic  murmur,  occasioned  partly  by  mitral  obstruction,  and 
partly  by  aortic  regurgitation.    Difficulty  also  repeatedly  arises 

1  In  illustration  of  this,  Dr.  Watson  details  the  particulars  of  a  very  remark- 
able case.  "  The  shock  of  this  man's  artery,"  he  says,  "  was  plainly  to  be  felt 
through  his  clothes,  by  one's  hand  laid  lightly  upon  the  bend  of  his  arm.  His 
wife  told  me,  that  for  five  years  past,  this  jarring  blow  had  made  it  uncomfort- 
able for  her  to  take  his  arm,  when  they  were  walking  together.  The  same  kind 
of  jerking  impulse  was  strikingly  perceptible  in  the  femoral  arteries,  and  in 
the  carotids."     ("  Practice  of  Physic,"  p.  25G,  1st  ed.) 


182  RHEUMATIC    INFLAMMATION    OF   THE   HEART, 

from  the  fact  that  one  morbid  sound  may  be  so  loud  and  promi- 
nent as  to  mask  and  render  almost  inaudible  another,  which, 
under  other  circumstances,  would  have  announced,  in  plain  and 
fearful  tones,  the  existence  of  disease  at  some  other  part.  But 
in  all  these  cases  the  form  or  forms  of  diseases  which  exist  may 
be  discovered,  and  their  combinations  pointed  out,  by  careful 
attention  to  the  rules  I  have  laid  down — by  careful  attention 
to  the  character  and  position  of  the  abnormal  sound,  to  the 
direction  in  which,  and  the  time  at  which,  it  is  heard,  and  to 
the  state  of  the  arterial  pulse. 

Our  diagnosis,  however,  is  not,  in  all  cases,  so  certain  or  so 
perfect  as  could  be  wished.  In  practice,  many  difficulties 
present  themselves  which  cannot  be  resolved  solely  by  attention 
to  the  sounds  themselves.  Sometimes,  for  instance,  at  the 
commencement  of  an  attack,  it  is  difficult  to  determine  whether 
a  sound,  evidently  abnormal,  but  of  an  indistinct  indefinite 
character,  be  referable  to  endocardial  or  exocardial  mischief, 
and  it  is  only  by  the  effect  of  firm  pressure  in  the  cardiac  region, 
and  by  the  variation  in  the  character  of  the  sound  observed  in 
the  course  of  oft-repeated  examinations,  conducted  while  the 
patient  is  in  different  postures,  that  it  is  possible  to  arrive  at  a 
correct  conclusion. 

So,  also,  it  sometimes  happens  that  an  ill-developed  indefi- 
nite sound,  having  its  origin  in  the  heart  or  its  membranes,  so 
closely  accompanies  the  respiratory  movements  as  to  make  it 
doubtful  whether  it  may  not  arise  from  the  lungs  or  pleurae. 
Here,  again,  the  position  of  the  sound  affords  no  information, 
but  the  question  may  be  set  at  rest  by  making  the  patient  hold 
his  breath,  when,  if  it  be  connected  with  the  respiratory  organs, 
it  will  instantly  cease,  but  will  continue  as  before  if  referable  to 
the  heart. 

Again,  it  is  frequently  doubtful  whether  an  endocardial 
murmur,  arising  in  the  course  of  acute  rheumatism,  may  not  be 
due  to  functional  causes.  The  question  is  one,  the  decision  of 
which  admits  not  of  delay,  as  on  it  depends  the  nature  of  the 
treatment,  and  the  well-being  of  the  patient.  Here  our  powers 
of  discernment  are  taxed  to  the  utmost,  for  it  is  only  by  refer- 


ITS    SYMPTOMS    AND    PROGRESS.  183 

ence  to  the  appearance  of  the  patient,  the  treatment  -which  has 
been  adopted,  the  nature  of  the  symptoms  by  which  the  acces- 
sion of  murmur  has  been  accompanied,  and  the  position  and 
character  of  the  sound  itself,  that  it  is  possible  to  arrive  at  a 
sound  conclusion.  According  as  the  patient  is  pale  and 
exsanguine  ;  as  the  murmur  varies  with  the  posture  of  the 
patient,  and  is  constantly  or  only  occasionally  present ;  as  it  is 
heard  most  distinctly  at  the  apex,  or  at  the  base  of  the  heart, 
and  in  the  track  of  the  aorta,  or  of  the  pulmonary  artery ;  as 
it  is  soft  and  blowing,  or  harsh  and  rasping  ;  as  it  is  more  or 
less  superficial ;  and  as  its  accession  has  been  attended  or 
unattended  by  pain  and  dyspnoea,  by  fluttering  or  irregularity 
of  the  pulse,  or  by  evidence  of  increased  cardiac  action,  so 
must  be  our  judgment.  No  certain  rule  can  be  laid  down  to 
enable  the  practitioner  to  estimate  correctly  the  importance  of 
each  indication ;  but  any  one  who  is  cautious,  and  watchful  for 
the  accession  of  cardiac  inflammation,  will  not  fail  to  give  a 
significant  interpretation  to  prsecordial  pain  and  increased  or 
irregular  cardiac  action  ;  while,  on  the  other  hand,  he  will  not 
overestimate  the  importance  of  a  systolic  murmur,  if  it  occurs 
in  a  pale  and  weakly  person  who  has  been  sweated  profusely, 
or  has  undergone  venesection,  more  especially  if  it  be  unac- 
companied by  pain  and  by  increased  or  irregular  action  of  the 
heart,  and  be  heard  most  distinctly  in  the  track  of  the  pulmo- 
nary artery. 

Thus  by  paying  careful  attention  to  the  circumstances  which 
characterize  each  case,  we  may  generally  arrive  at  a  correct 
conclusion,  and  if  we  are  sometimes  unable  to  do  as  much  as 
might  be  wished  toward  arresting  the  progress  of  the  disease, 
and  repairing  the  damage  it  has  occasioned,  it  is  at  least  satis- 
factory to  be  able  to  detect  its  existence,  and  to  feel  that,  being 
aware  of  its  nature,  we  are  in  a  position  to  do  all  that  can  be 
done  for  its  alleviation  or  cure. 

I  have  hitherto  spoken  only  of  the  physical  signs  of  rheu- 
matic carditis,  which  are  those  on  which  we  must  chiefly  rely 
for  the  detection  of  commencing  mischief  about  the  heart,  but 
the  general  symptoms  are  also  of  considerable  importance  by 


184 


RHEUMATIC    INFLAMMATION    OF    THE    HEART, 


directing!;  attention  to  the  seat  of  inflammation  and  excitinor 
alarm  for  the  safety  of  the  patient.  As  soon  as  active  mischief 
has  commenced,  the  whole  aspect  of  the  patient  is  rapidly 
changed,'  his  countenance,  which  only  a  short  time  before  had 
been  calm  and  tranquil,  becomes  anxious,  and  his  whole  manner 
and  deportment  show  but  too  clearly  that  serious  mischief  has 
supervened.  Sometimes  he  is  restless,  more  generally  he  lies 
quietly  flat  on  his  back,  and  evinces  inability  or  much  disincli- 
nation to  lie  on  his  left  side.  The  breathing,  which  before  had 
been  unafi"ected,  becomes  hurried  and  shallow,  and  often  ac- 
companied by  a  short  dry  cough;  he  complains  of  uneasiness 
and  oppression  at  the  epigastrium,  and  of  pain  in  the  praecordial 
region,  increased  on  every  attempt  at  full  inspiration,  as  also 
by  pressure  with  the  fingers  in  the  intercostal  spaces,  or  under 
the  cartilages  of  the  false  ribs  on  the  left  side.  He  suffers 
from  palpitation,  not  unfrequently  feels  faint,  and  sometimes 
experiences  a  sharp  pain,  almost  resembling  a  paroxysm  of 
angina,  shooting  through  the  chest  to  the  scapula,  or  upward 
to  the  clavicle  or  the  left  shoulder. 

These  symptoms  are  usually  more  marked  in  cases  of  peri- 
carditis than  in  those  in  which  the  endocardium  only  is  affected. 
Moreover,  they  are  apt  to  vary  according  to  the  nature  of  the 
inflammatory  products.  The  more  solid  the  character  of  the 
inflammatory  exudation,  and  the  smaller  the  amount  of  serum 
poured  out,  the  less  constrained  is  the  patient  in  his  posture, 
the  less  disposition  does  he  manifest  to  syncope,  and  the  longer, 
cceteris  paribus,  does  his  pulse  retain  its  force  and  regularity. 
On  the  other  hand,  the  larger  the  quantity  of  serum  poured 
out — the  more  tbe  pericardial  sac  is  distended — the  greater  is 
his  reluctance  to  move  or  change  his  posture,  the  greater  the 
disposition  to  fainting,  and  the  more  feeble,  irregular,  or  inter- 
mittent his  pulse.  Indeed,  when  the  effusion  is  very  great, 
whatever  position  he  may  have  assumed,  whether  on  his  back 

1  Dr.  riope,  in  noticing  this  peculiar  anxiety  of  countenance,  remarks  :  "The 
sardonic  expression  and  peculiar  contortion  of  the  features  attending  the  worst 
cases  of  pericarditis  are  occasioned  by  the  sympathy  subsisting  between  the 
respiratory  nerves  of  the  face  and  those  of  the  heart.  An  impression  is  con- 
veyed to  the  spinal  cord  through  the  pneumogastric  nerves,  and  is  reflected  to 
the  face  through  the  portio  dura." 


ITS    SYMPTOMS   AND    PROGRESS.  185 

or  on  his  side,  or  sitting  erect,  or  leaning  forward  with  his 
arms  upon  his  knees,  so  fearful  is  he  of  accelerating  his  heart's 
action,  embarrassed  as  it  is  by  the  amount  of  liquid,  that  he 
cannot  be  induced  to  change  his  posture. 

These  symptoms  of  cardiac  inflammation  are  extremely 
striking,  and  might  be  deemed  sufficient  of  themselves  to  indi- 
cate the  existence  and  nature  of  the  mischief;  but  unfortu- 
nately they  are  not  very  distinctive,  nor  are  they  very  con- 
stant in  their  occurrence.  Generally,  indeed,  when  the  heart 
is  attacked,  some  pain,  dyspnoea,  irregularity  of  the  pulse,  or 
some  other  indication  of  existing  disease,  dra^vs  attention  to 
the  seat  of  mischief.  But  I  have  repeatedly  seen  cases  in 
which  most  acute  pericarditis  has  been  set  up  and  has  con- 
tinued for  some  iiays,  without  the  supervention  of  any  symp- 
toms likely  to  direct  attention  to  the  action  which  was  going 
on ;  and  instances  not  unfrequently  occur  in  which  from  first 
to  last  such  general  symptoms  are  altogether  absent.^  There- 
fore when  treating  a  case  of  acute  rheumatism  we  must  never 
neglect  to  make  a  careful  examination  of  the  chest  as  day  by 
day  we  watch  the  progress  of  the  disease.  Absence  of  pain, 
and  other  general  symptoms  of  cardiac  affection,  may  serve  to 
mislead  the  unwary,  and  to  beguile  them  into  the  idea  that  the 
rheumatism  is  running  its  ordinary  course ;  but  the  more  cau- 
tious and  intelligent  practitioner  will  be  aware  that  the  absence 
of  such  symptoms  affords  no  guarantee  for  the  safety  of  his 
patient,  and  by  repeated  daily  examination  of  the  heart  he  will 
satisfy  himself  that  he  is  not  allowing  a  frightful  disease  to  run 
on,  unheeded  and  unchecked,  in  its  career.  He  will  listen  for 
the  to-and-fro  sound  of  pericardial  friction,  and  for  the  bellows- 
murmur,  which  announces  the  commencement  of  endocardial 
inflammation,  and  as  soon  as  his  ear  shall  have  given  him 
notice  of  their  existence,  either  separately  or  together — nay, 
even  before  the  sounds  are  fully  formed,  if  from  the  occurrence 
of  pain,  the  acceleration  or  irregularity  of  the  heart's  action, 

^  Cases  such  as  these,  in  wliich  carditis  has  been  unattended  by  any  local 
symptoms,  are  familiar  to  all  practical  men,  and  instances  have  been  placed  on 
record  by  Drs.  Andral,  Burrows,  Latham,* Stokes,  Watson,  and  others. 
13 


186  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

or  from  any  prolongation  or  roughness  of  its  sounds,  he  has 
reason  to  suspect  the  commencement  of  inflammation — he  will 
at  once  endeavor  to  arrest  its  progress  by  active  and  appro- 
priate treatment.  Nor  will  he  rest  satisfied  with  having  dis- 
covered its  existence ;  he  Avill  take  every  means  to  trace  its 
progress  in  order  that  he  may  be  able  to  apportion  his  remedies 
to  the  exigencies  of  the  case,  and  speak  with  some  certainty  as 
to  the  issue.  If  pericarditis  be  present  he  will  listen  anxiously, 
day  by  day,  for  some  increased  clearness  in  the  cardiac  sounds, 
and  some  diminution  in  the  intensity  of  the  friction-sound,  or 
in  the  extent  of  area  over  which  it  is  heard,  and,  by  care- 
ful percussion  in  the  prascordial  region,  he  will  ascertain 
whether  the  eff'usion  into  the  pericardial  sac  be,  or  be  not,  in 
process  of  absorption.  In  like  manner,  if  the  endocardial 
membrane  be  inflamed,  he  will  constantly  note  the  increase  or 
the  decrease  in  the  force,  frequency,  and  regularity  of  the 
heart's  action,  and  in  the  intensity  of  the  adventitious  bellows- 
murmur,  and  according  to  the  information  his  ear  aff"ords  him, 
so  in  great  measure  will  he  vary  his  treatment,  and  form  a 
favorable  or  unfavorable  diagnosis. 

I  have  hitherto  made  no  mention  of  one  peculiar  train  of 
phenomena  which  sometimes  accompany  rheumatic  carditis, 
because,  in  the  first  place,  their  occurrence  is  somewhat  rare ; 
and,  in  the  second,  they  are  apt  to  divert  attention  from  the 
real  seat  of  mischief,  and  are,  therefore,  deserving  of  especial 
notice.  I  allude  to  phenomena  resulting  from  disturbance  of 
the  cerebral  functions.  It  has  been  already  stated  that  a  great 
alteration  is  usually  observed  in  the  expression  of  the  patient, 
and  that  excessive  restlessness  sometimes  supervenes  as  soon 
as  inflammation  of  the  heart  is  set  up.  In  some  instances,  this 
excitement  of  the  nervous  centers  proceeds  to  a  very  much 
greater  extent.  The  restlessness  and  anxiety  pass  into  delirium, 
into  quiet  or  into  low  muttering  delirium,  often  attended  with 
stupor  ;  or,  on  the  other  hand,  into  wild  uncontrollable  delirium, 
into  the  delirium  of  mania,  accompanied  sometimes  by  tetanic 
spasms  or  by  convulsions,  which  terminate  either  in  extreme 
exhaustion  or  in  death  by  coma.     Such  cases  have  been  long 


ITS    SYMPTOMS    AND    PROGRESS.  187 

recognized  by  the  profession,  and  instances  in  point  have  been 
placed  on  record  by  many  accurate  and  observant  physiologists.^ 
In  many  respects  they  are  very  remarkable.  They  present  all 
the  symptoms  usually  observed  in  cases  of  meningeal  or  cere- 
bral inflammation,  yet  are  seldom  connected  with  any  struc- 
tural change  within  the  cranium  which  can  be  regarded  as 
indicative  of  inflammatory  action.  Sometimes,  indeed,  on  dis- 
section after  death  the  cerebral  veins  have  been  found  gorged, 
and  some  little  serum  has  been  discovered  eff"used  under  the 
arachnoid,  or  into  the  ventricles  of  the  brain,  but  this  has  been 
by  no  means  a  constant  occurrence,  and  even  had  it  been  so, 
would  only  have  shown  that  in  this,  as  in  all  other  forms  of 
violent  delirium,  the  circulation  in  the  brain  is  apt  to  be  inter- 
fered with,  and  serum  poured  out  in  consequence.  But  though 
in  most  of  these  instances  there  has  been  no  vestige  of  active 
mischief  within  the  cranium,  it  has  been  generally  far  other- 
wise with  the  heart  or  its  investing  membrane.  Serum  and 
recent  lymph  have  been  found  effused  into  the  pericardium,  or 
the  endocardial  membrane  has  been  inflamed,  and  recent  fibrin- 
ous vegetations  have  been  scattered  irregularly  over  the  sur- 
face of  the  left  auricle,  or  deposited,  in  the  shape  of  fringes, 
along  the  edges  of  the  valves.  Indeed,  so  constantly  has  cere- 
bral disturbance  been  associated  with  mischief  about  the  heart, 
that  many  have  been  inclined  to  regard  delirium,  occurring  in 
acute  rheumatism,  as  invariably  the  result  of  changes  going  on 
in  the  central  organ  of  the  circulation.  The  coincidence  is 
certainly  sufiiciently  frequent  to  render  it  imperative  upon  every 
practitioner  to  examine  most  carefully  into  the  condition  of  his 
patient's  heart,  whenever  symptoms  of  flightiness  or  delirium 
begin  to  manifest  themselves ;  but  it  must  not  be  concluded, 
without  examination,  that  the  heart  is  certainly  the  seat  of 
mischief,  for  cerebral  disturbance  does  occasionally  arise,  in 
acute  rheumatism,  as  a  result  of  cerebral  or  meningeal  inflam- 

^  In  France,  by  MM.  Andral,  Bouillaud,  and  Rostan ;  and  in  this  country,  by 
Drs.  Abercrombie,  R.  Bright,  Burrows,  Davis,  Latham,  Todd,  Watson,  and 
others  ;  several  striiiing  cases  of  this  sort  are  detailed  in  Cap.  X,  of  this 
Treatise. 


u 


188  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

motion ;  more  frequently  in  connection  vrith  pneumonia  or 
pleuritis ;  and  sometimes,  though  rarely,  Avithout  any  local 
internal  inflammation.  In  these  cases,  again,  the  stethoscope 
affords  invaluable  assistance,  inasmuch  as  it  enables  us  to  ascer- 
tain with  certainty  whether  there  be,  or  be  not,  mischief  about 
the  heart  or  lungs.  If  we  fail  in  detecting  mischief  in  the 
chest,  we  must  direct  our  attention  to  the  brain  and  its  envel- 
opes, while  if  we  discover  cardiac  or  pulmonary  inflammation, 
our  aim  should  be  to  subdue  the  morbid  action  there  taking 
place,  in  the  hope  that  the  cerebral  disturbance  may  be  sympa- 
thetic of  the  cardiac  or  pulmonary  mischief,  and  may  subside 
coincidently  with  its  cessation.^ 

In  summing  up  the  principal  facts  deserving  of  notice  in 
/  reference  to  rheumatic  inflammation  of  the  heart,  I  should  say 
that  it  is  incidental  to  all  the  stages  of  acute  rheumatism, 
occurring  sometimes  before  the  commencement  of  inflammation 
of  the  joints,  and  possibly  also,  in  some  rare  instances,  without 
the  concurrence,  from  first  to  last,  of  any  active  articular  symp- 
toms: it  arises  less  frequently  toward  the  close  of  the  disease, 
when  tending  to  a  favorable  termination,  than  it  does  at  its 
beginning  or  during  its  progress:  it  supervenes  most  frequently 
in  acute  attacks  of  the  disease,  more  especially  when  inflam- 
mation attacks  many  joints,  and  manifests  a  disposition  to  shift 
its  quarters:  and  it  is  much  more  commonly  met  with  in  the 
young  than  in  those  more  advanced  in  years;  more  frequently 
in  the  irritable  than  in  those  of  a  phlegmatic  temperament; 
more  usually  in  those  in  whom  the  fibrous  structures  about  the 
joints  are  chiefly  afl'ected,  than  in  those  who  sufier  principally 
from  synovial  inflammation.  As  the  general  symptoms  of  its 
accession  are  variable  and  uncertain,  and  are  sometimes  alto- 
gether absent,  the  physical  signs,  wliich  are  very  characteristic, 
should  be  jealously  watched  for,  the  chest  being  examined  daily 
by  the  stethoscope  and  by  percussion  throughout  the  progress 
of  the  disease.  On  the  first  indication  of  cardiac  mischief, 
active  means  should  be  taken  to  prevent  its  continuance,  and, 

1  For  full  particulars  regarding  the  cerebral  symptoms  which  occur  in  con- 
nection with  rheumatism,  see  Cap.  X,  of  this  Treatise. 


FATAL    CASES. 


189 


throughout  its  course,  the  physical  signs  should  be  carefully 
attended  to,  as  affording  the  only  certain  evidence  as  to  the 
action  of  the  remedies  and  the  progress  of  the  disease,  whether 
toward  a  favorable  or  unfavorable  termination.  Cseteris  paribus, 
the  prognosis  should  be  more  unfavorable  in  cases  accompanied 
by  a  copious  effusion  into  the  pericardium,  with  great  irregu- 
larity of  the  heart's  action,  than  in  those  in  which  a  smaller 
quantity  of  serum  is  poured  out,  and  the  heart  is  less  embar- 
rassed ;  more  guarded  in  those  accompanied  by  much  constitu- 
tional depression  than  in  those  marked  by  tolerance  of  remedial 
measures;  more  cautious  when,  together  with  the  cardiac 
inflammation,  there  coexists  inflammation  of  the  lungs  or 
pleura,  than  when  the  respiratory  organs  are  unaffected ;  and 
much  more  unfavorable  in  cases  complicated  by  cerebral  dis- 
turbance, than  in  those  in  which  the  intellect  remains  un- 
clouded. 

The  subjoined  abstract  of  sixteen  cases  of  acute  rheumatism 
which  proved  fatal,  in  St.  George's  Hospital,  under  the  care 
of  the  physicians,  during  the  six  years  ending  December  31, 
1850,  Avill  show  the  important  part  which  cardiac  inflammation 
ordinarily  bears  in  producing  a  fatal  termination,  as  also  the 
age  and  sex  of  the  sufferers,  and  the  general  character  of  the 
post-mortem  appearances.^ 

The  ages  of  the  patients  were  thus  distributed; 


Fata]  cases,  under  the  age  of 15 

"          between  the  ages  of     .     .     .    15-20 
"                 "             "                               20-25 
"                 "             "                               25-30 

Total 

Male. 

Female. 

Total. 

1 
3 

2 
2 

1 
4 

1 
2 

2 
7 
3 
4 

8 

8 

IG 

1  In  the  Post-mortem  Register,  preserved  in  the  Museum  of  St.  George's 
Hospital,  will  be  found  full  particulars  of  all  these  cases.  The  history  of  those 
which  occurred  prior  to  May,  1848,  is  reported  by  myself;  of  those  which 
occurred  subsequently  to  that  date,  by  Dr.  Barclay,  who  succeeded  me  as 
Medical  Registrar  of  the  Hospital.  The  post-mortem  appearances  are  recorded 
by  Mr.  Prescott  Hewett,  Mr.  G.  D.  Pollock,  Dr.  Ilandlield  Jones,  Mr.  Gray,  and 
Mr.  Holl,  the  successive  curators  of  the  Museum. 


190  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

The  particulars  of  these  cases  are  given  below.  One  other 
case,  which  occurred  in  the  person  of  a  man,  set.  27,  proved 
fatal,  in  the  year  1846,  but,  as  no  post-mortem  examination 
was  made,  I  have  omitted  all  mention  of  the  symptoms  during 
life. 


History. 

Case  I. — Mary  Ann  Harrison,  set.  14. — Xo  previous  attack 
of  acute  rheumatism. 

Ailing  thirteen  days.  Redness  and  swelling  of  the  joints, 
and  pneumonia,  thirteen  days  before  her  death. 

Pericarditis  and  endocarditis,  four  days. 

Occasional  delirium,  and  choreic  twitching  of  the  voluntary 
muscles,  three  days. 

Post-mortem  Examination. 

The  Joints  and  Sheaths  of  Tendons  were  slightly  increased 
in  vascularity,  and  contained  a  thick,  tenacious  fluid,  in  which 
numerous  irregularly  granular  globules  were  discovered  by  the 
microscope.     There  were  no  true  pus-globules. 

In  the  Pericardium  was  serum,  with  large  quantities  of 
recently  eflfused  lymph,  which  here  and  there  had  formed 
slight  adhesions  between  the  two  layers  of  the  pericardial 
membrane. 

Tlie  Mitral  and  Aoj'tic  Valves  were  red  and  swollen,  and 
presented  on  their  surface  and  edges  of  contact,  recent  fibrin- 
ous vegetations  of  a  pink  color. 

The  Left  Lung  was  in  a  state  of  red  hepatization  almost 
throughout. 

The  Right  Lung  was  loaded  with  red,  frothy  serum,  and 
in  one  or  two  parts  was  passing  into  the  condition  of  red 
hepatization. 

The  Kidneys,  Liver,  and  other  Viscera  were  healthy. 


fatal  cases.  191 

History. 

Case  II. — Frances  Webster,  aet.  18. — One  previous  attack 
of  acute  rheumatism  three  years  ago. 

Ailing  fifty-one  days.  Inflammation  of  the  joints,  forty-four 
days  before  her  death. 

Pericarditis  and  endocarditis,  forty-three  days. 

Pleurisy  and  pneumonia,  thirty  days. 

Slight  peritonitis,  four  (?)  days. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  universally  adherent  to  the  heart  by  soft,  recent 
adhesions,  in  which  minute  anastomosing  red  lines  could  here 
and  there  be  traced. 

3Iitral  and  Aortic  Valves  loaded  with  recent  fibrinous 
vegetations. 

Right  Pleural  Cavity  contained  an  immense  quantity  of 
recent  lymph  and  serum. 

Left  Pleural  Cavity  contained  recent  lymph  and  serum, 
though  in  a  smaller  quantity. 

Right  Lung  inflamed  in  the  lower  part ;  the  remaining  por- 
tions of  its  structure  carnified  by  pressure. 

Left  Lung  inflamed ;  loaded  with  red,  frothy  serum,  and  in 
parts  hepatized. 

Slight  Peritonitis,  with  recent  adhesions  between  the  liver 
and  diaphragm. 

Kidneys,  Liver,  and  other  Viscera  healthy  in  structure,  but 
congested. 


History. 

Case  III. — Thomas  Howship,  set.  16. — No  previous  attack 
of  acute  rheumatism. 

Suffering  twelve  months  from  an  eruption,  resembling  ich- 
thyosis, on  the  legs. 

Redness  and  swelling  of  the  joints  supervened  suddenly, 


192  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

eleven  days  before  his  death,  on  the  rapid  subsidence  of  the 
cutaneous  eruption.  For  two  days  before  the  rheumatism 
showed  itself  in  the  joints,  he  had  alternate  vomiting  and  diar- 
rhoea, which  ceased  immediately  on  the  appearance  of  the 
articular  symptoms. 

Inflammation  of  the  kidneys,  five  days.  Pericarditis,  four 
days.     Double  pleurisy,  four  days. 

Occasional  delirium  and  slight  opisthotonos,  two  days. 

Urine  contained  pus  and  blood. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  excessively  injected,  and  coated  with  a  thick 
layer  of  recent  lymph,  and  containing,  in  its  cavity,  serum, 
shreds  of  lymph,  and  a  small  quantity  of  pus. 

Valves  healthy. 

Recent  adhesions  of  the  Pleurce  at  the  lower  part  on  either 
side. 

Lungs  congested,  but  still  crepitant. 

Kidneys  congested.  Mucous  membrane  of  the  pelvis,  infund- 
ibula,  and  calices,  inflamed  and  covered  with  a  large  quantity 
of  recently  eff"used  lymph. 

Liver  and  other  Viscera  healthy. 


History. 

Case  IV. — James  Palmer,  set.  27. — One  previous  attack 
of  acute  rheumatism  eighteen  months  ago,  and  palpitation  ever 
since. 

Rheumatism,  with  occasional  redness  and  swelling  of  the 
joints,  two  months,  for  which  he  was  admitted  into  the 
hospital. 

Slight  papular  cutaneous  eruption  twenty  days  before  death. 

Rigors,  with  alternate  diarrhoea  and  vomiting,  followed  by 
great  increase  of  the  rheumatic  symptoms,  and  relief  of  the 
sickness  and  purging,  four  days. 

Erysipelas  of  the  face,  two  days.     Delirium,  one  day. 


fatal  cases.  193 

Post-mortem  Examination. 

Joints. — Right  knee  and  left  wrist  contained  a  large  quantity 
of  viscid  fluid  mixed  with  Ijmph  and  pus.  The  synovial  mem- 
brane lining  these  joints  was  extremely  vascular.  The  sheaths 
of  the  tendons  at  the  back  of  both  wrists  contained  a  quantity 
of  thick  puriform  fluid,  but  the  tendons  at  the  fore  part  of  the 
joints  were  healthy.  The  synovial  membrane  lining  the  left 
knee-joint  was  somewhat  increased  in  vascularity,  and  the  joint 
contained  a  larger  quantity  of  synovia  than  natural,  but  the 
fluid  was  healthy  in  appearance. 

Pericardium  universally  adherent  to  the  heart  by  old  adhe- 
sions, and  adherent  also  to  the  anterior  parietes  of  the  chest. 

Valves  healthy. 

Lungs  healthy. 

Kidneys  congested,  and  coarse  in  structure,  but  smooth  on 
their  surface. 

Liver  and  other  Viscera  congested,  but  healthy  in  structure. 


History. 

Case  V. — Jane  Lawes,  aet.  16. — Had  an  attack  of  acute 
rheumatism  ten  weeks  ago,  followed  by  irregular  rheumatic 
pains,  which  have  continued  ever  since. 

Second  attack  ushered  in  by  rigors,  followed  by  inflammation 
of  the  joints,  twenty-three  days  before  her  death. 

Pericarditis,  from  seventeen  to  twenty-three  days  ? 

Pleurisy,  eleven  days. 

Post-mortem  Examination. 

Joints. — Both  knee-joints  were  examined,  but  no  traces  of 
inflammation  were  found  remaining. 

Pericardium  enormously  distended  by  serum  tinged  with 
blood,  and  containing  massed  of  lymph  floating  in  it.  The 
free  surfaces  of  the  pericardium  were  covered  by  a  very  thick 
coating  of  recent  lymph,  and  had  contracted  partial  adhesions 
with  each  other  at  the  posterior  surface  and  at  the  apex  of  the 
heart. 


194  RHEUMATIC    INFLAMMATION    OF   THE    HEART, 

Endocardium  on  tlie  left  side  white  and  opaque,  but  without 
vegetations. 

Valves  otherwise  healthy. 

Right  Pleural  Cavity  obliterated  partly  by  old,  partly  by 
recent  adhesions. 

Left  Pleural  Cavity  contained  a  small  quantity  of  recently 
effused  lymph  and  serum. 

Lungs  congested,  and  the  lower  lobe  of  the  left  one  com- 
pressed by  the  distended  pericardium. 

Kidneys  large  and  congested,  but  healthy  in  structure. 

Spleen  soft  and  grumous,  with  numerous  white  corpuscles  in 
its  structure. 

Otlier  Viscera  congested,  but  healthy  in  structure. 


History. 

Case  VI. — Edward  Jeynes,  set.  27. — No  previous  attack  of 
acute  rheumatism. 

Had  scarlatina  three  months  ago,  and  had  never  been  well 
since. 

Redness  and  swelling  of  the  joints  supervened  six  days 
before  death. 

Insensibility  and  stertorous  breathing  came  on  while  he  was 
in  a  vapor  bath,  and  he  died  in  about  twenty  minutes. 

Post-mortem  Examination. 

Joints. — Healthy  in  appearance.  Unusual  quantity  of  syn- 
ovia in  the  elbow-joint. 

Cranium. — Membranes  healthy.  Brain  not  abnormally  con- 
gested :  healthy  in  structure.  Ventricles  contained  the  usual 
quantity  of  clear  fluid.  Veins  at  the  upper  surface  of  the 
hemispheres  were  very  turgid,  and  filled  with  thick,  dark,  fluid 
blood.     Arteries  at  the  base  of  the  brain  quite  healthy. 

Pericardium  in  one  part  presented  increased  vascularity, 
and  its  cavity  contained  a  small  quantity  of  opaque  fluid,  in 
which  were  floating  some  small  specks  of  fibrin. 


FATAL    CASES.  195 

Heart  somewhat  dilated,  and  its  muscular  structure  flaccid. 
Walls  of  left  ventricle  thinner  than  natural.  Valves  quite 
healthy.  Endocardium  deeply  blood-stained.  Blood  fluid, 
thick  and  dark  colored. 

Lungs  congested,  discolored,  and  somewhat  emphysematous 
anteriorly.     Otherwise  healthy. 

Spleen  pale,  soft,  and  pultaceous,  and  somewhat  larger  than 
natural. 

Kidneys  and  other  Viscera  healthy. 


History. 

Case  VII. — Sarah  Woodason,  aet.  29. — One  previous  attack 
of  acute  rheumatism  ten  years  ago. 

Frequently  suffered  from  wandering  rheumatic  pains  during 
the  last  ten  years. 

Long  out  of  health,  suff"ering  from  leucorrhoea  and  relaxed 
sore  throat. 

Repeated  rigors,  followed  by  very  severe  wandering  pains, 
with  profuse  acid  perspirations  twenty-three  days  before  her 
death. 

Inflammation  of  the  joints  eighteen  days  before  her  death. 

Profuse  perspiration,  mercurial  diarrhoea.  Sloughing  of  the 
back  and  hips. 

Post-mortem  Examination. 

Sloughs  over  both  Trochanters,  which  had  burrowed  some 
distance  under  the  integuments. 

Joints. — In  the  left  wrist-joint  was  a  greatly  increased  quan- 
tity of  synovial  fluid,  mixed  with  a  small  quantity  of  pus.  In 
the  left  knee-joint  was  an  increased  quantity  of  synovia,  which 
was  thicker  and  more  yellow  than  natural ;  and  floating  in  it 
were  two  large  pieces  of  lymph,  the  largest  nearly  three  inches 
in  length,  and  a  quarter  of  an  inch  broad  at  its  greatest 
diameter. 

Pericardium  contained  a  small  quantity  of  serum,  and  at 


196  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

the  base  of  the  left  ventricle  presented  a  small  spot  of  ecchy- 
mosis  and  some  increased  vascularity;  and  at  this  spot  was  a 
small  speck  of  lymph,  which  could  be  easily  peeled  off. 

Valves. — Mitral  valve  somewhat  thickened.  Aortic  valves 
healthy. 

Slight  recent  adhesions  of  the  Pleurce  existed  at  the  upper 
and  outer  side  of  the  chest  on  either  side. 

Lungs  congested,  but  healthy. 

Kidneys,  Liver,  and  other  Viscera  healthy. 


History. 


Case.  VIII. — George  Smith,  set.  16. — One  previous  attack 
complicated  by  inflammation  of  the  heart  two  years  ago. 

Present  attack  commenced  with  wandering  pains  in  the 
limbs  twenty-one  days  before  his  death. 

Increase  in  the  severity  of  the  pains,  eighteen  days. 

Profuse  rheumatic  perspiration,  but  no  redness  or  swelling 
of  the  joints. 

Pericarditis,  eighteen  days. 

Died  suddenly. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  almost  universally  adherent  to  the  heart, 
partly  by  old  adhesions,  partly  by  more  recently  effused 
lymph.  At  the  root  of  the  large  vessels  the  lymph  was  still 
soft  and  jelly-like. 

Heart  enormously  enlarged,  and  somewhat  hypcrtrophied. 
The  cavity  of  the  left  ventricle  would  almost  admit  the  entire 
hand. 

Valves. — The  aortic  and  mitral  valves  were  both  somewhat 
thickened,  and  the  aortic  rather  rigid.  The  tendinous  cords 
of  the  mitral  valve  were  remarkably  developed. 

Lungs  congested,  but  crepitant  and  healthy. 

The  Kidneys,  Liver,  and  other  Viscera  healthy. 


fatal  cases.  197 

History. 

Case  IX. — Richard  Huntley,  aat  17. — No  history  of  any 
previous  attack  of  rheumatism. 

Redness  and  swelling  of  the  joints  commenced  twenty-seven 
days  before  death. 

Pericarditis  between  eighteen  and  twenty-seven  days.  The 
exact  period  uncertain.  It  existed  at  the  time  of  his  admis- 
sion into  the  hospital,  when  also  he  was  in  a  state  of  salivation. 

Endocarditis.  Exact  period  of  its  commencement  uncer- 
tain. 

Pneumonia  about  twelve  days. 

Pleurisy  about  five  days. 

Larse  abscess  in  the  left  axilla,  stated  to  have  existed  from 
the  beginning  of  the  attack. 

Slight  delirium  previous  to  death. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  contained  a  large  quantity  of  blood-stained 
serum.  Its  free  surface  was  covered  throughout  b}'-  a  thick 
layer  of  recent  lymph,  some  of  which  was  deeply  blood-stained, 
and  some  of  which  was  also  becoming  organized,  and  pre- 
sented a  vascular  appearance. 

Valves. — Mitral  more  opaque  than  natural,  somewhat 
swollen,  and  loaded  on  the  auricular  side  with  recent  pink 
fibrinous  deposits.  Along  the  edges  of  contact,  on  the  ven- 
tricular surface  of  the  aortic  valves,  were  recent  fibrinous 
vegetations. 

Right  Pleural  Cavity  contained  a  large  quantity  of  blood- 
tinged  fluid. 

Left  Pleural  Cavity  contained  blood-stained  fluid,  and  at 
its  lower  part  a  small  quantity  of  recent  lymph,  forming  a 
coating  to  the  lung  in  that  situation. 

Rigid  Lung  gorged  with  frothy  serum,  and  at  is  lower  and 
back  part  were  several  patches  of  red  hepatization. 

Left  Lung  was  also  gorged  with  frothy  red  serum,  and  pre- 
sented several  patches  of  red  hepatization 


198  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

The  Right  Kidney  appeared  somewhat  coarse ;  tlie  Left, 
congested,  but  healthy. 

The  Liver,  Spleen,  and  other  Viscera  congested,  but  per- 
fectly healthy  in  structure. 


History. 

Case.  X. — Elizabeth  Moore,  aet.  20. — No  history  of  any  pre- 
vious attack  of  acute  rheumatism. 

Was  confined  about  nine  weeks  and  a  half  before  her  death, 
and  the  catamenia  appeared  once  afterward. 

Wandering  rheumatic  pains  five  weeks  and  a  half  before 
death. 

Redness  and  swelling  of  the  joints  began  twenty-three  days 
before  death. 

Pericarditis,  sixteen  days.     Endocarditis,  fifteen  days  ? 

Bronchitis,  fifteen  days. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  much  distended  by  serum,  mixed  with  flakes 
of  lymph ;  the  whole  of  its  free  surface  was  covered  by  a 
thick  coating  of  lymph. 

Valves. — Along  the  edges  of  the  mitral  valves,  on  the  au- 
ricular surface,  was  a  small  fringe  of  recent  fibrinous  vegeta- 
tions ;  and  the  ventricular  surface  of  the  aortic  valves  was 
slightly  coated  with  recent  lymph. 

The  Pleurse  were  partially  adherent  by  old  firm  adhesions, 
but  presented  no  trace  of  recent  inflammation. 

The  Lungs  were  loaded  with  serum  and  frothy  mucus,  but 
were  crepitant  throughout,  and,  anteriorly,  somewhat  emphy- 
sematous. 

The  Kidneys,  Liver,  and  other  Abdominal  Viscera  were 
congested,  but  healthy. 


fatal  cases.  199 

History. 

Case  XI. — Elizabeth  Adams,  set.  30. — No  previous  attack 
of  acute  rheumatism. 

Present  illness  began,  without  previous  indisposition  (?), 
by  redness  and  swelling  of  the  joints,  twelve  days  before 
death. 

Pericarditis  and  endocarditis  from  nine  to  five  days  before 
death. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  contained  a  small  quantity  of  serum.  The 
membrane  itself  was  highly  vascular,  and  covered  by  a  coat- 
ing of  recently  effused  lymph. 

Heart. — Tissue  flaccid  ;  under  the  microscope  a  large  num- 
ber of  oil-globules  were  detected  in  its  structure. 

Valves. — Aortic  healthy.  Mitral  fringed  with  recent  fibrin- 
ous vegetations,  which  extended  over  both  its  auricular  and 
ventricular  surfaces. 

Pleurse  and  Lungs  healthy. 

Liver  much  enlarged,  and  very  fatty  in  appearance. 

Kidneys  somewhat  coarse  in  structure  and  granular  on  their 
surface. 

Spleen,  Uterus,  and  other  organs  congested. 


History. 


Case  XII. — Catherine  Doyley,  set.  17. — Two  previous 
attacks  of  acute  rheumatism. 

"  Out  of  sorts,"  and  suffering  from  hysteria  six  days  before 
the  commencement  of  redness  and  swelling  of  the  joints,  which 
began  eighteen  days  before  her  death.  Inflannuation  of  the 
joints  only  lasted  two  or  three  days. 

Pericarditis  and  endocarditis  thirteen  days  before  death. 

Pleurisy  five  or  six  days.     Sank  gradually. 


200  rheumatic  inflammation  of  the  heart, 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium. — Thickly  covered  on  its  free  surface  by  a 
coating  of  recent  lymph,  which  had  contracted  tolerably  firm 
adhesions,  gluing  the  A'isceral  and  parietal  layers  of  the  mem- 
brane together  throughout  their  whole  extent,  excepting  on 
the  outer  side  corresponding  to  the  outer  side  of  tiie  right 
ventricle. 

Heart. — Its  cavities  dilated  and  its  walls  hypertrophied, 
particularly  those  of  the  right  side. 

Valves. — Mitral  somewhat  thickened  and  covered  on  its 
auricular  surface,  and  more  particularly  along  its  edges  of  con- 
tact, by  recent  fibrinous  vegetations.  Similar  vegetations  were 
also  found  on  the  ventricular  side  of  the  aortic  valves,  along 
their  edges  of  contact.     Valves  on  the  right  side  healthy. 

Partial  old  adhesions  of  the  right  pleura. 

Rigid  Lung  infiltrated  by  frothy  serum. 

Partial  old  adhesions  o-f  the  left  pleura,  and  effusion  of 
serum,  and  recent  lymph  at  the  lower  part  of  the  pleural  cavity, 
gluing  the  lobes  of  the  lung  together,  and  its  base  to  the  serous 
lining  of  the  diaphragm. 

Left  Lung  infiltrated  by  frothy  serum. 

Kidneys  healthy. 

Liver  healthy,  but  its  capsule  thickened  by  the  effusion  of 
fibrin  into  its  structure. 

Spleen  contained  numerous  deposits  of  fibrin  about  the  size 
of  a  millet-seed. 


History. 

Case  XIII. — John  Hodges,  ret.  21. — No  history  of  any  pre- 
vious attack  of  acute  rhcum'atism. 

Seized  with  pain  in  the  head,  and  wandering  pains  in  the 
limbs  eight  days  before  death. 

Redness  and  swelling  of  the  joints  began  five  days  before 
his  death. 


FATAL    CASES.  201 

Heart  symptoms,  five  days. 

Had  a  slight  fit  with  ptosis  of  one  eyelid  a  few  hours  before 
death. 

Post-mortem  Examination. 

Joints. — Both  knee-joints  contained  a  quantity  of  whitish, 
opaque,  glairy  fluid,  which  appeared  under  the  microscope  to 
be  synovia  containing  a  large  number  of  pus-corpuscles.  The 
synovial  membrane  was  highly  vascular. 

Pericardium  contained  about  four  ounces  of  an  opaque  fluid, 
in  which  floated  numerous  shreds  of  lymph.  The  free  surface 
was  covered  by  a  coating  of  recent  lymph,  which,  on  the 
anterior  surface  of  the  heart,  had  begun  to  contract  adhesions. 
The  membrane  was  highly  congested,  and  in  one  or  two  spots 
presented  small  patches  resembling  ecchymosis. 

Valves  healthy. 

Both  Pleural  Cavities  contained  a  small  quantity  of  thin, 
transparent  serum. 

Both  Lungs  were  quite  healthy  and  crepitant  throughout. 

Kidneys,  Liver,  and  other  abdominal  organs  congested,  but 
healthy. 

A  large  clot  of  fibrin,  resembling  jelly  both  in  appearance 
and  consistence,  was  found  in  the  cavity  of  the  pelvis.  There 
was  no  trace  of  inflammation  there. 


History. 

Case  XIV. — Ann  Amess,  set.  21. — Slight  rheumatism  one 
year  ago,  but  no  previous  acute  attack. 

Inflammation  of  the  joints  seventeen  days  before  death. 

Palpitation  and  pain  in  the  chest,  ten  days. 

Miliary  eruption  of  sudamina,  seven  days. 

Delirium,  more  or  less,  three  days;  violent,  twelve  hours. 

Post-mortem  Examination. 

Joints. — The  synovial  membrane  of  both  knee-joints  was 
14 


202  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

higlily  vascular  and  red.  In  the  cavity  of  the  joints  was  a 
cjuantity  of  turbid,  yellow  serum,  in  which  floated  masses  of 
coagulated  lymph,  one  of  which  was  deeply  stained  with  blood. 
The  cartilages  of  the  joints  were  clear  and  white. 

Brain  presented  nothing  remarkable. 

Pericardium  contained  a  small  quantity  of  slightly  turbid 
serum. 

Heart  and  Valves  perfectly  healthy. 

Lungs  healthy ;  a  few  old  adhesions  existed  in  the  right 
pleural  cavity. 

Peritoneum  contained  a  small  quantity  of  turbid  serum. 

Liver,  Kidneys,  and  other  Viscera  in  the  abdominal  cavity 
congested,  but  healthy. 


History, 

Case  XV. — Mark   ]\Iindenhall,  set.   12. — Several  previous 
attacks  of  acute  rheumatism  ;    one  when  he  was  six  years  old. 
Ailing,  eighteen  days. 
Inflammation  of  the  joints,  fifteen  days. 
Palpitation  and  endocarditis,  at  least  eleven  days. 
Pericarditis,  seven  days. 
Pneumonia.      Duration  uncertain. 
Pleurisy.     Occasional  delirium.     Excessive  dyspnoea. 

Post-mortem  Examination. 

Joints  not  examined. 

Pericardium  contained  some  serum,  and  a  large  quantity  of 
•lymph,  which  had  formed  partial  slender  adhesions  over  the 
ventricles. 

Heart  somewhat  hypertrophied  and  dilated. 

Valves. — Recent  fibiinous  vegetations  on  the  mitral  and 
aortic  valves.  Old  thickening  of  the  mitral  valve.  Slight 
recent  thickening  of  the  tricuspid  valve. 

Right  Pleural  Oavity  contained  several  ounces  of  serum, 
mixed  with  recent  lymph. 


FATAL    CASES.  203 

Lungs  congested  throughout ;  in  the  lower  half  on  either 
side  inflamed,  and  in  parts  in  a  state  of  gray  hepatization. 

Kidneys,  Liver,  and  other  Abdominal  Viscera  congested, 
but  healthy. 


History. 

Case  XVI. — William  Davis,  aet.  25. — No  previous  attack 
of  acute  rheumatism.  Rheumatic  symptoms  began  fourteen 
days  before  his  death. 

Delirium  with  much  tremor,  more  or  less  three  days.  Furious, 
one  day. 

Pericarditis,  a  few  hours. 

Post-mortem  Examination. 

Joints. — Right  sterno-clavicular  articulation  softened,  and 
surrounded  by  thick,  yellow  pus.  Pus  also  in  the  left  elbow 
and  in  the  right  ulno-carpal  articulation,  and  extending  along 
the  tendons. 

Membranes  of  the  Brain  congested.  Slight  effusion  in  the 
subarachnoidean  cellular  tissue. 

Brain  congested.     Ventricles  filled  with  serous  fluid. 

Pericardium  contained  a  small  quantity  of  turbid  serum, 
and  on  the  surface  of  the  left  auricle  was  a  small  quantity  of 
plastic  lymph. 

Valves  perfectly  healthy. 

Lungs  and  Pleurse  healthy. 

Kidneys,  Liver,  and  other  Abdominal  Viscera  healthy. 


CHAPTER  VIII. 

RHEUMATIC    INFLAMMATION    OF    THE    HEART,  ITS 
TREATMENT. 

Having  traced  the  causes  and  described  the  symptoms  of 
Rheumatic  Carditis,  it  now  only  remains  for  me  to  discuss  its 
treatment.  How  far  is  it  possible  to  prevent  its  occurrence  ? 
How,  when  it  has  once  commenced,  can  its  course  be  controlled, 
or  its  progress  arrested  ?  How,  when  its  active  symptoms  have 
been  subdued,  can  the  lesions  it  has  left  behind  be  modified  or 
got  rid  of?  Can  we  fairly  hope  to  cut  short  an  attack  of  peri- 
carditis, to  induce  absorption  of  the  matters  effused,  and  to 
prevent  adhesion  of  the  two  layers  of  the  pericardium  ?  Or, 
when  inflammation  of  the  endocardium  has  been  set  up,  can  we 
fairly  anticipate  a  victory  over  the  disease,  and  a  restoration 
of  the  .conditions  of  health  ?  These  are  indeed  important 
questions,  and  demand  our  full  and  anxious  consideration. 

I  have  already  stated  my  conviction,  that  when  once  peri- 
carditis or  endocarditis  has  commenced,  recovery,  in  the  strict 
sense  of  the  word,  is  extremely  improbable.  There  may  be 
apparent  recovery ;  the  patient  may  so  far  get  well  as  to 
resume  his  ordinary  occupations,  and,  if  they  be  not  laborious, 
he  may  live  for  years,  without  experiencing  much  ill  effect 
from  his  attack  of  rheumatism.  But  in  most  cases  his  subse- 
quent career  will  be  short,  and  exceedingly  distressing.  Before 
many  years  have  elapsed,  he  will  begin  to  suffer  from  asthma 
and  palpitation,  as  tlie  effect  of  his  former  cardiac  seizure  ;  and, 
after  death,  the  hypertrophy  and  dilatation  of  the  heart,  with 
the  whole  train  of  symptoms  which  have  caused  his  protracted 
suffering  and  have  terminated  in  his  premature  death,  will  be 
found  to  have  arisen  from  disease  of  the  valves,  or  from  adhe- 
sion of  the  two  layers  of  the  pericardial  membrane,  the  result 
of  the  former  cardiac  inflammation. 


RHEUMATIC    INFLAMMATION    OF    THE    HEART.  205 

It  is  obviously,  therefore,  of  the  utmost  importance  to  take 
every  precaution  against  the  occurrence  of  a  disease  which  is 
followed  by  such  serious  consequences.  We  are  bound  not 
only  to  employ  active  measures  as  soon  as  it  has  made  its  ap- 
pearance, but  to  use  every  means  which  experience  has  pointed 
out  to  guard  against  its  invasion.  I  will  not  stop  to  refer  to  the 
influence  of  particular  remedies  in  exciting  or  warding  off  its  at- 
tack, as  the  whole  subject  resolves  itself  into  a  question  respect- 
ino;  the  best  treatment  for  the  alleviation  of  rheumatism,  and 
this  has  been  fully  discussed  in  a  previous  chapter.  There  is 
one  method  of  treatment,  however,  to  which  has  been  attributed 
such  especial  power  in  this  respect,  that  I  feel  bound  to  make 
particular  allusion  to  it.  I  refer  to  calomel,  administered  in 
repeated  doses,  so  as  to  affect  the  mouth. 

It  has  been  asserted  that,  by  putting  the  system  under  the 
influence  of  mercury,  it  is  possible  to  ward  off  cardiac  inflam- 
mation. No  statement,  however,  can  be  more  erroneous,  or 
more  mischievous  :  erroneous,  because  pericarditis  is  frequently 
set  up  while  the  system  is  fully  under  the  influence  of  mercury ; 
mischievous,  because  ptyalism  forms  a  grievous  addition  to  the 
miseries  of  the  disease,  very  frequently  causes  excessive 
depression,  and  thus  tends  to  give  an  unhealthy  character  to 
the  inflammatory  products  ;  and  because  by  its  presence  we 
are  deprived  of  a  remedy  which,  administered  in  due  season, 
and  with  a  proper  regard  to  the  exigencies  of  the  case,  proves 
most  valuable  in  promoting  those  actions  whereby  the  extent 
of  the  mischief  is  limited,  and  absorption  of  the  inflammatory 
products  induced.  Calomel,  when  given  during  the  progress 
of  inflammation  in  a  healthy  person,  is  assuredly  one  of  our 
most  powerful  auxiliaries  ;  but  when  given  so  as  to  affect  the 
constitution  before  the  commencement  of  cardiac  inflammation, 
it  not  only  has  no  influence  in  preventing  the  disease,  but  by 
the  irritability  and  general  depression  which  it  occasions, 
appears  to  modify  its  course  in  a  manner  by  no  means  con- 
ducive to  recovery.  In  five  instances  I  have  seen  acute  peri- 
carditis supervene  at  a  time  when  the  patient  was  profusely 
salivated,  and  in  every  case  the  ptvalism  appeared   to  operate 


206  EHEUMATIC    INFLAMMATION    OF   THE    HEART, 

prejudicially.^  The  inflammation  partook  but  slightly  of  the 
adhesive  character,  the  pericardium  became  enormously  dis- 
tended "with  fluid,  absorption  of  this  fluid  was  with  difficulty 
produced,  and  in  two  of  the  cases  death  was  the  result.  Nor 
is  pericarditis  the  only  complication  which  I  have  known 
occur,  in  spite  of  the  existence  of  mercurial  action.  Endo- 
carditis and  pleurisy  have  also  supervened  at  a  time  when  the 
system  has  been  under  the  full  influence  of  mercury ;  and  in 
all  such  cases  the  inflammation  has  run  its  course  as  if  no  mer- 
curial action  had  existed. 

But  although  calomel  and  opium  have  no  power  of  prevent- 
ing the  access  of  cardiac  inflammation,  those  remedies  which 
fulfill  the  purpose  of  relieving  the  general  symptoms  of  the 
disease,  are,  to  a  great  degree,  safeguards  for  the  heart  :  what- 
ever is  the  best  treatment  for  an  uncomplicated  attack  of  acute 
rheumatism,  the  same  affords  the  surest  guarantee  against  its 
various  complications.  Whether  venesection,  or  guaiacum,  or 
opium  be  employed,  or  whetlier  colchicum,  calomel,  alkalies, 
or  purgatives,  the  heart  will  be  protected  from,  or  exposed  to, 
the  risk  of  inflammation,  according  as  each  remedy  is  admin- 
istered judiciously.  If  venesection  be  employed  in  the  weak 
and  cachectic,  or  if,  even  in  the  strong,  it  be  carried  beyond  the 
necessity  of  the  case,  it  will  surely  cause  irritability  of  the 
heart,  and  favor  the  extension  of  inflammation  to  it.  If,  on 
the  other  hand,  it  be  omitted  altogether  when  vascular  action 
is  excessive,  when  the  heart  is  beating  violently  and  turbu- 
lently,  and  secretion  is  defective  or  suspended,  its  omission 
will  as  certainly  expose  the  heart  to  mischief,  by  leaving  it  in 
a  state  of  excitement,  which  might  have  been  mitigated  or  sub- 
dued by  the  aid  of  a  moderate  blood-letting.  And  so  with 
every  remedy  which  can  be  named.     Its  virtue  in  warding  ofi' 

1  ••  1  have  never  seen  more  of  ragged  pulpy  deposit  on  the  surface  of  the 
heart  from  recent  inflammation  of  its  investing  membrane,  than  in  the  case  of 
a  j'oung  woman,  who  was  brought  some  five  or  sixj-ears  ago  into  St.  George's 
Hospital,  (shortly  before  her  death,)  profusely  salivated  in  sequel  of  rheumatic 
fever."  (••  Observations  on  the  true  Character  of  Acute  Rheumatism,''  by  Dr. 
Wilson,  Senior  Physician  to  St.  George's  Hospital.  "  Lancet"  for  1844,  vol. 
ii,  p.  254.) 


f 


\ 


ITS    TREATMENT.  207 

cardiac  inflammation  varies  according  to  the  circumstances 
under  which,  and  the  judgment  with  wliich,  it  is  employed,  and 
coincides  exactly  with  its  virtue  in  alleviating  the  general 
symptoms  of  the  disease.  The  treatment  or  the  remedy 
which,  under  any  given  conditions  of  age,  temperament, 
and  severity  of  symptoms,  is  most  effectual  in  curing  the 
disease,  the  same  is  that  which  will  be  found  most  useful  in 
preventing  its  extension,  whether  to  the  heart,  the  lungs,  or 
any  other  part  of  the  body. 

Unfortunately,  do  what  we  will,  we  cannot  always  guard 
against  the  access  of  cardiac  inflammation.  Oftentimes  before 
we  see  our  patient,  inflammation  of  the  heart  or  its  membranes 
has  commenced,  and  sometimes,  even  in  spite  of  our  efforts,  it 
will  supervene  while  our  patient  is  under  treatment.  There- 
fore it  becomes  necessary  to  consider,  not  only  how  to  guard 
against  its  invasion,  but  how  to  combat  its  symptoms  when 
once  they  have  commenced.  For  although,  under  such  cir- 
cumstances, we  can  seldom  if  ever  do  all  we  desire  for  our 
patient's  recovery  ;  though  we  can  seldom  or  never  prevent 
his  heart  sustaining  some  permanent  damage,  we  may  at  least, 
by  early  and  appropriate  treatment,  do  much  toward  staving 
off"  the  final  catastrophe.  We  may  arrest  the  disease  in  its 
progress  of  destruction  ;  we  may  lessen  the  amount  of  damage 
inflicted ;  and  by  thus  diminishing  the  impediments  to  tlie  cir- 
culation, we  may  greatly  defer  the  day,  which  sooner  or  later 
is  certain  to  arrive,  in  which  the  heart,  suffering  from  the  effect 
of  successive  changes,  all  resulting  from  the  primary  mischief, 
shall  no  longer  be  able  to  do  its  work  efficiently,  and  shall  thus 
indirectly  prove  the  efficient  cause  of  asthma,  dropsy,  suff"oca- 
tion,  and  death. 

What,  then,  are  the  pathological  conditions  to  be  treated,  the 
ends  for  which  means  are  to  be  found  ?  First,  there  is  the 
morbid  condition  of  the  blood  ;  the  primary  source  of  all  the 
mischief.  This  obviously  must  be  corrected  as  far  as  possible. 
Secondly,  there  is  the  local  inflammation  ;  and  this  must  be 
subdued  at  all  hazards,  if  we  hope  to  save  our  patient  from 
immediate  death.     Thirdly,  there  are  the  products  of  inflam- 


208  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

mation  ;  and  these  must  be  got  rid  of,  if  we  Avish  to  prolong  his 
days,  and  to  save  him  from  the  consequences  of  a  damaged 
heart.  In  a  previous  chapter^  the  treatment  which  is  best 
adapted  to  fulfill  tlic  first  of  these  objects,  has  been  fully 
pointed  out ;  the  second  calls  for  bleeding,  and  calomel,  and 
opium  ;  and  the  third  for  blisters,  diuretics,  and  absorbents. 

Of  all  the  remedies  forthecure  of  rheumatic  inflammation 
of  the  heart,  venesection  is  that  most  generally  adopted.  M. 
Bouillaud  has  employed  it  very  largely  in  France ;  and  even 
here  it  has  numerous  and  strenuous  advocates.  Observation, 
however,  has  not  led  me  to  form  a.  favorable  estimate  of  its 
curative  power.  In  some  few  instances  it  has  been  useful  in 
expediting  the  action  of  other  remedies,  and  in  moderating  the 
force  and  frequency  of  the  pulse  when  the  patient  has  been 
robust,  and  the  heart's  action  turbulent  and  excessive.  But  in 
general  it  has  afforded  very  little  relief.^  It  has  usually  failed 
in  subduing  the  pain,  and  has  produced  only  a  temporary  im- 
pression on  the  pulse.  On  the  other  hand,  the  arguments 
against  its  indiscriminate  emploj'ment  are  numerous,  practical, 
and  weighty.  It  certainly  is  not  necessary  for  the  cure  of  the 
disease,  as  I  have  myself  effected  many  cures  without  it ;  it  is 
not  productive  of  safety  to  the  patient,  for  M.  Bouillaud  lost 
six  out  of  eighteen  patients  attacked  by  the  disease ;  whereas, 
out  of  eighty-seven  cases,  of  which  I  have  notes,  in  which  it 
was  not  employed,  two  only  proved  fatal,  one  of  Avhich  was  a 
case  of  pericarditis,  which  occurred  in  a  weak  debilitated  per- 
son, and  was  complicated  by  low  quick-spreading  inflammation 

1  ChaptPr  V.  pp.  112-118. 

2  I  am  glad  to  quote,  in  confirmalion  of  my  opinion,  the  views  of  those 
sound  practical  physicians,  Drs.  Latham,  Todd,  and  Watson.  The  former 
remarks,  "  my  treatment  of  endocarditis  has  not  been  vigorously  antiphlogistic. 
I  have  seldom  employed  venesection  at  all,  and  never  largely,"  yet,  "  it  has  not 
in  a  single  instance  proved  fatal  under  my  care ;"  whereas,  M.  Bouillaud's 
treatment  has  always  been  vigorously  antiphlogistic  ;  he  has  employed  large 
and  rei)eated  bleedings,  "in  spite  of  which,  he  has  had  to  record  numerous 
instances,  in  which  endocarditis  terminated  fatally  under  his  management." 
Dr.  Todd,  in  the  same  si)irit,  says,  "  my  experience  leads  me  to  value  very 
lightly  the  efficacy  of  general  bleeding  in  inliammation  of  the  heart ;"  and  Dr- 
Watson  reports,  that  he  '-seldom  opens  a  vein  in  these  cases." 


; 


ITS    TREATMENT.  209 

of  the  pleura.  And,  lastly,  it  is  often  prejudicial  to  the  patient 
bj  exhausting  his  strength,  rendering  him  liable  to  relnpses, 
and  altogether  protracting  his  recovery.  There  also  appears 
strong  reason  for  doubting  whether,  as  suggested  by  Dr,  Wat- 
son, "  bleeding  to  such  an  extent  as  to  bring  the  heart's  action 
to  a  pause  in  deliquium,"  may  not  tend  to  favor  the  deposition 
of   fibrin  upon  the  valvular  apparatus. 

General  blood-letting  then  should  be  employed  in  rheumatic 
carditis,  under  precisely  the  same  circumstances  as  in  cases  of 
acute  rheumatism  uncomplicated  by  cardiac  inflammation.  As 
a  remedy  to  be  exclusively  relied  upon,  it  is  quite  unavailing, 
and  often  extremely  dangerous  :  as  an  expedient  to  be  era- 
ployed  in  aid  of  other  remedies,  it  is  occasionally  of  the 
greatest  service.  If  a  patient  be  robust  and  plethoric,  with  a 
pulse  characterized  by  extreme  fullness  or  hardness,  it  may  be 
had  recourse  to  with  the  greatest  advantage,  and  may  be 
repeated  until  some  impression  is  produced  on  the  circulation. 
In  such  persons  it  assists  in  allaying  the  inflammation,  and 
favors  the  action  of  mercury  and  other  remedies.  But  in 
ordinary  cases  its  employment  is  unnecessary,  and  therefore 
inexpedient.  It  tends  to  diminish  the  red  globules  in  the 
blood  when  they  are  already  below  the  healthy  standard,  to 
render  more  irritable  the  already  irritable  and  excited  heart, 
and  to  favor,  as  I  believe,  the  formation  of  fibrinous  deposits 
on  the  valves.  Moreover,  if  carried  beyond  the  exigencies  of 
the  case,  it  may  cause  an  adhesive  inflammation  to  assume  a 
serous  or  suppurative  character,  and  may  prevent  that  peculiar 
and  most  valuable  action  of  mercury,  whereby  the  extent 
of  inflammation  is  limited,  and  its  products  absorbed  and  got 
rid  of. 

But  although  bleeding  from  the  arm  is  seldom  advisable, 
local  blood-letting  is  often  very  serviceable.  Leeches  may  be 
placed  over  the  region  of  the  heart,  or  blood  may  be  abstracted 
by  cupping,  and  thus  more  obvious  and  more  immediate  benefit 
will  be  obtained,  and  a  greater  impression  produced  on  the 
disease  as  manifested  by  the  pulse,  the  stethoscope,  and  the 
sensations    of  the    patient,    than    by    the    most    copious    and 


210  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

repeated  general  blood-letting.  Not  unfrequcntly  the  precordial 
pain  ceases,  the  heart's  sounds  become  clearer,  and  the  pulse 
softer,  even  while  the  leeches  are  doing  their  work. 

It  is  sometimes  a  question  whether  leeching  or  cupping  is 
the  more  appropriate  remedy  in  these  cases  :  and  some  persons 
recommend  the  employment  of  the  former,  while  others  as  stren- 
uously advocate  the  latter.  My  own  experience  inclines  me  to 
give  a  decided  preference  to  leeches.  They  are  quite  as  easy 
of  application,  and  are  free  from  the  objection  very  properly 
urged  against  cupping,  of  causing  pressure  upon  the  ribs  at  a 
spot  where,  in  the  inflamed  condition  of  the  heart,  the  least 
pressure  and  the  least  percussion  cannot  fail  to  be  productive  of 
mischief;  and,  although  this  difficulty  may  be  in  some  meas- 
ure overcome  by  applying  the  cupping-glasses  between  the  left 
scapula  and  the  vertebral  column,  I  still  incline  most  strongly 
to  leeches ;  for  1  have  never  known  cupping  produce  the  same 
amount  of  benefit  that  I  have  often  seen  result  from  leeching. 
Nor  is  it  difficult  to  suggest  an  explanation  of  the  fact.  By 
cupping,  blood  is  often  abstracted  as  copiously,  and  almost  as 
rapitlly,  as  by  venesection  from  the  arm,  whereas  leeches  do 
their  work  more  slowly,  and  by  their  gradual  and  continued  drain 
tend  perhaps  to  cause  some  revulsion  from  the  deeper-seated 
structures.  Be  this  as  it  may,  they  certainly  aft'ord  an  amount 
of  relief  out  of  all  proportion  to  the  quantity  of  blood  abstracted 
through  their  agency,  and  incomparably  greater  in  the  majority 
of  cases  than  can  be  obtained  by  venesection  from  the  arm,  or 
by  cupping  as  ordinarily  practiced.  If  the  force  and  fullness 
of  the  pulse  be  such  as  to  require  blood-letting  for  its  relief,  or 
if  the  patient  be  so  plethoric  as  to  render  it  desirable  to  let 
blood  witii  the  view  of  expediting  the  action  of  remedies,  then 
bleeding  from  the  arm  is  the  most  appropriate  treatment.  If, 
on  the  contrary,  the  patient  be  pale  and  weakly,  and  the  pTBse 
not  more  than  ordinarily  forcible,  then,  if  blood-letting  be 
deemed  advisable  for  the  relief  of  the  prsecordial  pain  and 
anguish,  leeching,  and  not  general  bleeding,  should  be  had 
recourse  to.      Cupping  should   be  reserved   for  tliose  cases  in 


1 


ITS    TREATMENT.  211 

which  a  copious  bleeding  is  required,  and  in  which  blood  does 
not  flow  freely  from  the  arm. 

Mercury,  like  bleeding,  is  a  valuable  remedy  in  rheumatic 
carditis.  Powerfully  antiphlogistic  in  the  influence  it  exerts, 
it  assists  in  moderating  the  intensity,  and  in  limiting  the 
extent  of  inflammatory  action  ;  and  having  done  so,  it  operates 
as  blood-letting  does  not,  it  promotes  the  absorption  of  the 
matters  efi"used.  Having  first  of  all  checked  the  progress  of 
the  disease,  it  subsequently  lends  its  aid  to  the  process  of 
reparation. 

It  is  obvious,  then,  that  no  case  of  rheumatic  carditis, 
occurring  in  a  strong  and  healthy  person,  can  be  safely  treated 
without  mercury.  It  may  be,  and  indeed  is,  generally  unneces- 
sary to  have  recourse  to  its  antiphlogistic  property  so  long  as 
inflammation  is  confined  to  the  joints,  inasmuch  as  rheumatic 
articular  inflammation  does  not  ordinarily  tend  to  structural 
disorganization.  But  as  soon  as  the  heart  or  its  membranes 
are  implicated,  the  whole  complexion  of  the  case  is  altered.  It 
is  no  longer  a  question,  then,  whether  the  inflammation  may 
not  be  resolved  without  structural  mischief ;  the  mere  fact  of 
there  being  inflammation,  implies  structural  changes  of  a  grave 
and  momentous  character, — changes  which  must  be  arrested  if 
life  is  to  be  preserved,  and  which,  when  arrested,  must  be 
modified  or  got  rid  of  if  life  is  to  be  prolonged.  Changes,  too, 
they  are,  which  occur  most  rapidly,  and  are  slow  and  difiicult 
of  removal,  so  that  no  time  must  be  lost  in  pressing  to  its  ful- 
fillment, the  treatment  considered  most  efficacious  against  their 
extension.  For  this  purpose  mercury,  of  all  known  remedies, 
is  that  on  which  most  reliance  can  be  placed.  It  does  not 
supersede  other  remedial  agents,  but  it  comes  most  powerfully 
and  beneficially  to  their  aid.  It  sustains  the  good  eff"ect  pro- 
duced by  blood-letting ;  it  calms  the  violence,  alters  the  char- 
acter, and  circumscribes  the  limits  of  the  local  inflammation  ; 
it  stimulates  the  absorbents  to  the  business  of  repair,  and  pro- 
motes the  continuance  of  the  natural  secretions  at  a  time  when 
they  are  checked,  and  well-nigh  suspended  by  the  shock  the 
system  has  sustained. 


212  RHEUMATIC    INFLAMMATION    OF    THK    HEAHT, 

But  to  insure  these  effects  the  remedy  must  be  pushed  until 
its  impression  on  the  constitution  is  unequivocally  declared  by 
the  occurrence  of  ptyalism.  Three  or  four  grains  of  calomel 
combined  with  opium,  in  sufficient  quantity  to  prevent  its  run- 
ning off  by  the  bowels,  may  be  given  every  four  hours,  and  if 
it  be  considered  desira])le  still  further  to  hnsten  the  access  of 
salivation,  mercurial  inunction  may  also  be  had  recourse  to. 
In  such  a  case,  a  drachm,  or  a  drachm  and  a  half  of  the  strong 
mercurial  ointment  may  be  rubbed  in,  night  and  morning,  on 
the  abdomen  or  the  inside  of  the  thighs;  or  a  blister  may  be 
applied  to  the  region  of  the  heart,  and  mercurial  dressing 
applied  to  the  blistered  surface.  Thus,  sometimes,  in  the 
course  of  the  second,  and  generally  within  three  or  four  days, 
a  full  mercurial  action  will  be  produced.  Then,  and  not  until 
then,  have  we  any  guarantee  that  the  medicine  has  found  its 
way  into  the  system,  and  that  its  beneficial  influence  Avill  be 
displayed.  But  as  soon  as  salivation  has  commenced,  and 
even  sooner  in  some  instances,  the  symptoms  manifestly  im- 
prove ;  the  pain  and  anguish  begin  to  subside,  the  pulse  becomes 
quieter  and  steadier,  apd  the  heart's  sounds  clearer.  The 
cessation  of  the  to-and-fro  sound  of  friction  in  one  case,  or  in 
another  its  recurrence  coincidently  with  the  decrease  of  pme- 
cordial  dullness,  denotes  the  absorption  of  fluid  from  the  peri- 
cardium; while,  if  there  be  mischief  within  the  heart,  the 
diminished  intensity  of  the  endocardial  murmur,  and  the 
greater  regularity  of  the  heart's  action,  give  intelligence  of 
improvement  in  that  quarter.  These  are  facts  to  which  I  can 
testify  from  repeated  observation,  and  I  have  so  often  seen  all 
antiphlogistic  remedies  employed,  and  yet  no  sensible  amend- 
ment produced  until  after  ptyalism  has  commenced,  that  I 
cannot  doubt  as  to  the  cause  of  the  improvement. 

In  this,  as  in  all  other  serous  inflammations,  it  will  sometimes 
be  found  difficult  to  obtain  the  constitutional  effect  of  mercury. 
It  may  be  administered  freely  for  a  considerable  time,  and 
may  be  guarded  carefully  by  full  doses  of  opium,  and  yet  no 
mercurial  fetor  be  perceived,  no  evidence  of  mercurial  action 
obtained.     But  it  must  not,  therefore,  be  inferred  that  its  ex- 


1 


ITS    TREATMENT.  213 

hibition  is  useless.  As  opium,  when  acting  beneficially  in 
delirium  tremens,  and  acute  rheumatism,  may  be  given  in 
enormous  doses  without  occasioning  either  stupor  or  consti- 
pation ;  so,  when  the  constitution  is  sound,  and  inflammation 
violent  and  extensive,  mercury,  while  exercising  a  most  bene- 
ficial influence  over  the  course  of  the  disease,  may  sometimes 
prove  tardy  in  producing  salivation.  It  seems  as  if,  under 
such  circumstances,  its  whole  power  were  expended  in  allaying 
the  diseased  action;  and  it  fairly  admits  of  question,  whether 
the  difiiculty  experienced  in- producing  salivation,  may  not  be 
taken,  cseteris  paribus,  as  a  test  of  the  extent  and  activity  of 
the  morbid  action,  and  of  the  necessity  for  the  early  and  active 
administration  of  mercury  to  control  and  arrest  its  course. 
Certain  it  is  that,  in  ray  experience,  the  difficulty  of  inducing 
salivation  has  varied,  cseteris  paribus,  according  as  the  patient 
has  been  strong  and  healthy,  the  inflammatory  symptoms 
unusually  high,  and  the  inflammation  extensive,  and  of  that 
peculiar  character  which  tends  to  the  eff'usion  of  plastic  and 
highly  organizable  lymph. 

Mercury,  though  generally  beneficial  in  rheumatic  carditis, 
is  not  equally  so  in  all  constitutions.  In  robust  and  habitually 
healthy  persons,  it  seldom  gives  rise  to  much  constitutional 
irritation  or  depression,  and  when  the  inflammation  is  exten- 
sive, it  produces  its  specific  action  slowly,  and  acts  most  bene- 
ficially on  the  course  of  the  disease.  In  such  cases,  therefore, 
it  can  hardly  be  employed  too  fearlessly  or  too  vigorously. 
But  in  the  weakly,  the  irritable,  and  the  unhealthy,  its  consti- 
tutional eifects  often  supervene  rapidly,  are  extremely  violent 
in  their  character,  and,  in  some  instances,  frightfully  depress- 
ing, and  hence  it  is  productive  of  injurious  consequences  by 
favoring  a  tendency  to  serous  or  suppurative,  instead  of  to 
adhesive  inflammation.  To  such,  therefore,  it  cannot  be  ad- 
ministered too  cautiously.  In  the  one  set  of  cases  it  is  essential 
for  the  arrest  of  inflammation  at  a  time  when  life  is  threatened 
by  its  extreme  intensity;  and  the  object  being  to  produce  a 
forcible  impression  on  the  disease  as  rapidly  as  possible,  it  can 
hardly  be  given  too  largely  or  pushed  too  vigorously.     But  in 


214  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

the  other,  the  system  is  readily  depressed,  and  when  depressed, 
is  prone  to  set  up  unhealthy  inflammation.^  Therefore,  although 
it  may  be  sometimes  deemed  expedient  to  obtain  mercurial 
action  in  such  cases,  it  is  most  desirable  so  to  administer  the 
remedy  as  that  the  system  shall  not  suffer  from  its  operation. 
In  the  first,  it  should  be  given  in  large  doses,  frequently  re- 
peated in  proportion  as  the  inflammation  is  active,  and  its 
progress  rapid.  In  the  last,  if  it  be  given  at  all,  it  should  be 
exhibited  in  smaller  doses,  and  at  longer  intervals,  and  at  the 
least  symptom  of  its  action,  its  administration  should  be  sus- 
pended. 

Some  persons  have  lately  attempted  to  undervalue  the  cura- 
tive influence  of  mercury  in  pericarditis,-  and  others,  though 
not  denying  its  efficacy  in  many  forms  of  inflammation,  have 
yet  contended  that  the  cure  of  pericarditis,  occurring  in  con- 
nection with  rheumatism,  may  be  safely  intrusted  to  other 
remedies.^  Now  although,  as  already  stated,  I  do  not  counsel 
the  indiscriminate  employment  of  mercury,  and,  in  some  rare 
instances,  do  not  administer  it  even  in  the  most  cautious  man- 
ner, yet  I  cannot  accord  my  assent  to  a  mode  of  practice  which 
would  deprive  us  of  what,  in  many  cases,  proves  our  most 
powerful  ally.  Other  remedies  very  often  suffice  in  that  form 
of  inflammation  which  occurs  in  weakly  or  cachectic  persons ; 
indeed,  the  administration  of  mercury  is  seldom  of  much  avail 
in  such  cases,  and  is  often  prejudicial  to  the  patient's  safety, 
especially  when  the  kidneys  are  diseased.  But  I  am  fully 
persuaded  that,  in  the  acute  and  sthenic  form  of  pericarditis, 
as  it  presents  itself  in  persons  of  a  strong  and  healthy  consti- 
tution, nothing  is  of  greater  service  than  the  remedy  in  question. 

'  This,  at  least,  I  can  positively  assert,  that  in  six  cases  which  have  fallen 
under  my  observation,  in  which  mercurial  action  has  been  accomj'anied  by 
much  constitutional  depression,  the  accession  of  salivation  has  been  marked 
by  the  disappearance  of  the  to-and-fro  sound  of  pericardial  friction,  with  coin- 
cident extension  of  the  priccordial  dullness,  and  increase  in  the  distance  and 
feebleness  of  the  heart's  sounds,  and  that  the  effusion  thus  unequivocally 
declared,  has  been  slowly  and  with  difficulty  removed. 

2  See  some  papers  published  in  the  "Medical  Times"  for  1849,  by  Dr.  John 
Taylor,  of  Huddersfield. 

3  See  a  paper  by  Dr.  J.  Risdon  Bennett,  in  the  "  Lancet"  for  Dec.  G,  1851. 


ITS    TREATMENT.  215 

No  such  case  c;m  be  treated  safely  without  its  administration. 
Recoveiy  may  take  phice,  in  certain  instances,  without  it,  as 
indeed,  Avithout  any  other  remedy,  but  that  is  an  argument 
which  applies  to  almost  every  disease,  and  to  every  kind  of 
treatment,  and  there  is  no  other  remedy  of  whose  curative 
influence  experience  and  observation  have  supplied  such  abund- 
ant and  unequivocal  proofs,  as  of  mercury  in  active  serous 
inflammation.  Its  efficacy,  hoAvever,  varies  very  remarkably, 
according  to  the  class  of  cases  in  which  it  is  employed,  as  also 
to  the  mode  in  Avhich  it  is  administered,  and  it  is  not  surprising, 
therefore,  that  persons  who  have  exhibited  it  largely,  in  all 
cases  of  pericarditis,  should  have  met  with  some  in  which  it 
has  been  not  inoperative  only,  but  actually  prejudicial  to  the 
safety  of  the  patient.  In  most  of  such  cases,  the  blame  should 
not  be  charged  upon  the  remedy,  but  upon  those  who  have 
injudiciously  administered  it,  for,  given  in  due  season  and  with 
proper  regard  to  the  exigencies  of  the  case,  no  remedy  is  more 
powerful,  and  few  are  so  trustworthy. 

Opium  is,  of  all  remedies,  that  which  comes  most  powerfully 
in  aid  of  blood-letting  and  mercury.  Roused  and  excited  as 
the  vascular  and  nervous  systems  are  by  the  violence  of  the 
morbid  action,  and  the  pain  which  attends  it,  all  remedies  prove 
comparatively  useless  if  unaccompanied  by  the  sedative  influence 
of  this  narcotic.  The  constant  pain,  with  the  absence  of  sleep, 
and  the  constitutional  irritation  consequent  thereupon,  do  more, 
I  believe,  to  exhaust  a  patient's  strength,  and  counteract  the 
actions  essential  to  his  recovery,  than  blood-letting  and  mercury 
can  do  to  promote  them.  In  every  case,  therefore,  of  I'hcumatic 
carditis,  opium,  in  full  doses,  is  indispensable.  It  should  be 
given  not  only  in  doses  adequate  to  restrain  the  purgative 
action  of  the  calomel,  but  in  quantity  sufiicient  to  assuage  the 
pain  and  allay  the  irritability.  From  tAvo-thirds  of  a  grain  to 
a  grain,  or  even  more,  should  be  prescribed,  in  the  form  of  a 
pill,  in  combination  with  calomel,  every  three  or  four  hours ; 
and  in  the  intervals,  if  there  be  much  pain,  it  is  expedient  to 
administer  eight  or  ten  minims  of  the  tincture,  or  of  Battley's 


216  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

sedative  solution.^  To  the  weak  and  irritable,  to  whom  mercury 
is  of  little  service,  it  proves  peculiarly  valuable.  It  not  only 
subdues  pain,  but  it  allays  irritability  and  procures  sleep,  and 
I  am  satisfied  that  many  of  my  patients  would  have  fallen 
victims  to  the  disease,  had  not  their  strength  been  husbanded 
by  its  sedative  influence. 

It   is  probable,  however,   that   opium   exercises   some  more 
directh'  curative  influence.     In  these  cases  of  pericarditis,  the 
two  inflamed   surfaces  are  in  constant  motion  and  rub  against 
one  another;  their  innervation  is  exaggerated,  their  irritability 
exalted.     Now,  although  opium  cannot,  of  itself,  prevent   the 
continuance  of  this  friction,  it  can  blunt  the  sensibility  of  the 
inflamed  membrane,  and  make  it  less  obnoxious  to  the  effect  of 
irritation.     Just,  as  before  cardiac  inflammation  has  been  set 
up,  opium  may  exercise  a  sedative  influence  on  the  heart,  and 
thus  may  render  it  less  prone  to  be  aff"ected  by  the  irritation  of 
the  rheumatic   poison,  so,  also,  I  believe,  after  the  commence- 
ment of  mischief,  opium  may  subdue  and  tranquilize,  and  thus 
prevent  that  excess  of  irritation  whereby  the  course  of  inflam- 
mation   is    prolonged,   and   its  products  made   to   assume    an 
unhealthy  character.     In  several  instances  of  pericarditis  in 
which,  in  spite  of  venesection  and  mercury,  inflammation  has 
continued   unabated,  while  the  constitutional   irritability  has 
been  excessive,  and  the  heart's  action  rapid  and  violent,  I  have 
seen  the  mercury  omitted  and  opium  administered  alone,  with 
the  happiest  and  most  speedy  results.     The  pain  has  ceased,  the 
patient   has   obtained  sleep,  his   irritability  has   subsided,  the 
pulse  has  fallen  in  frequency,  and  has  increased  in  steadiness, 
and  the  stethoscope,  no  less  than  the  general  symptoms  of  the 
disease,  has  testified  to  the  reality  of  the  improvement.     The 
same  train  of  symptoms  was  also  observed  in  two  cases  in  which, 
from  the  w^eak  and  cachectic  condition  of   the  patients,  I  was 
fearful  of   inducing  mercurial   action,    and   therefore   trusted 
exclusively  to  full  doses  of  opium  with  alkalies,  diuretics,  and 
repeated   blistering.     The  sedative  apparently  contributed  as 

•  I  find  that  in  these  cases,  Opium  itself  is  usually  preferable  to  the  Salts  of 
Morphia. 


ITS    TREATMENT.  217 

much  to  the  patients'  recovery,  as  it  manifestly  did  to  their 
comfort. 

Another  most  important  remedy  in  rheumatic  pericarditis  is 
a  large  blister  applied  to  the  chest.  In  the  early  stage  of  the 
attack,  especially  in  the  young  and  vigorous,  I  am  more  inclined 
to  confide  in  leeches  ;  but  when  once  effusion  has  taken  place, 
blistering  is  of  all  local  remedies  the  most  serviceable.  Indeed, 
its  efficacy  appears  to  vary,  in  some  measure,  according  to  the 
amount  of  li<|uid  effusion,  its  virtue  being  most  unequivocally 
displayed  when  the  amount  of  fluid  is  greatest.  In  such  cases 
an  immediate  diminution  in  the  prgecordial  dullness,  together 
with  greater  clearness  in  the  heart's  sounds,  is  often  observed 
as  the  result  of  a  large  and  efficient  blister. 

While  applying  leeches  and  blisters,  and  in  some  instances 
pushing  mercury  to  salivation,  the  other  general  indications 
must  not  be  lost  sight  of.  Though  pericarditis  or  endocarditis 
be  present,  they  are  still  rheumatic,  due  to  the  same  cause,  and 
requiring  the  same  general  treatment  for  their  relief,  as  does 
the  articular  inflammation.  Alkalies,  diuretics,  and  colchicum 
•  are  still  necessary  to  counteract  and  get  rid  of  the  materies 
morbi  to  which  all  the  mischief  owes  its  origin,  and  without  the 
removal  of  which  it  is  difficult  to  conceive  that  a  cure  can  be 
effected.  Not  only  are  they  conducive  to  the  elimination  of 
the  rheumatic  virus,  they  also  afford  most  powerful  aid  to 
blisters  and  mercury,  in  removing  the  fluid  products  of  inflam- 
mation. They  first  assist  in  counteracting  and  getting  rid  of 
the  cause  of  the  disease,  and  then  in  repairing  the  mischief  it 
has  occasioned.  In  endocarditis  more  especially,  alkalies  and 
the  neutral  salts,  more  particularly  the  salts  of  ammonia,^  prove 
eminently  useful ;  for,  by  helping  to  maintain  the  solubility  of 
the  fibrin,  and  so  preventing  its  deposition  on  the  valves,  they 
guard  against  a  lesion  which,  by  the  consecutive  changes  to 
which  it  gives  rise,  leads  surely  and  rapidly  to  an  untimely 
death. 

In  all  cases,  without  exception,  rest  and  abstinence  are  of 
the  utmost  importance.     No  treatment  can  be  satisfactory  in 

1  See  Dr.  Richardson's  "  Astley  Cooper  Prize  Essay"  for  1856. 
15 


218  RHEUMATIC    INFLAMMATION    OF   THE    HEART, 

its  issue,  unless  perfect  rest  be  enjoined,  and  every  cause  of 
excitement  carefully  guarded  against.  This  has  been  repeat- 
edly forced  upon  my  attention  in  the  strongest  possible  manner. 
In  several  instances  in  Avliich  patients  liave  worked  themselves 
into  a  state  of  excitement,  in  conse(juence  of  the  dread  inspired 
by  the  thoughts  of  being  leeched,  or  cupped,  or  bled,  every 
symptom  has  been  aggravated,  in  spite  of  the  remedies  employed. 
Indeed,  so  strikingly  was  this  the  case  in  one  instance,  that  I 
was  obliged  to  omit  all  local  treatment,  and  to  trust  entirely  to 
mercurials  and  diuretics,  with  opium  in  full  and  repeated  doses. 

One  other  point  still  remains  for  consideration — What 
symptoms  are  sufficient  to  warrant  such  a  presumption  of  the 
existence  of  cardiac  inflammation  as  to  justify  the  commence- 
ment of  active  treatment? 

This  question  hardly  admits  of  a  definite  answer,  inasmuch 
as  the  symptoms  Avhicli  mark  the  accession  of  carditis  are  of  a 
complex  nature,  and,  moreover,  are  uncertain  and  variable  in 
their  existence.  In  most  instances  some  exocardial  friction- 
sound  is  heard,  or  an  endocardial  murmur  accompanying  the 
heart's  sounds ;  and,  together  with  this,  there  is  anxiety  of  coun-* 
tenance,  and  prsecordial  pain  and  anguish,  with  dyspnoea,  pal- 
pitation, and  irregularity  in  the  heart's  action.  In  such  cases 
there  can  be  little  doubt  as  to  the  existence  of  inflammation, 
and  no  hesitation,  therefore,  as  to  the  course  to  be  pursued. 
The  same  holds  good  whenever  the  physical  signs  of  inflamma- 
tion are  present,  even  though  some  of  the  general  signs  be 
wanting.  In  other  instances,  however,  our  attention  may  be 
called  to  the  sudden  accession  of  precordial  pain  occurring 
coincidently  with  turbulence,  or  fluttering,  or  irregularity  of 
the  heart's  action;  and  yet,  on  examining  the  heart  most 
carefully,  we  may  fail  in  detecting  the  slightest  physical  indi- 
cation of  existing  mischief.  What  is  to  be  done  in  such  a 
dilemma?  Are  we  to  trust  implicitly  in  the  general  symp- 
toms, which  are  on  all  hands  admitted  to  be  uncertain  and 
fallacious,  or  are  we  to  delay  taking  active  measures  until  the 
presence  of  inflammation  has  been  rendered  indubitable  by  the 
presence  of  the  auscultatory  signs  ?     The  cautious  practitioner 


) 


ITS    TREATMENT.  219 

will  not  allow  himself  to  be  unduly  biased  in  one  direction  or 
the  other.  The  general  symptoms  must  not  be  relied  upon 
too  implicitly,  neither  must  the  absence  of  inflammation  be 
inferred,  simply  because  as  yet  there  is  no  murmur  nor  rough- 
ness with  the  sounds  of  the  heart.  Occasionally  a  murmur 
does  not  arise  until  inflammation  has  made  some  progress,  and 
we  are  bound,  therefore,  to  commence  our  treatment  before 
this  symptom  is  developed.  Indeed,  the  frequent  occurrence 
of  cardiac  inflammation  gives  such  a  significance  to  precor- 
dial pain,  dyspnoea,  and  palpitation,  occurring  in  the  course 
of  acute  rheumatism,  that  even  if,  on  listening  most  carefully 
to  the  heart,  we  are  unable  to  detect  the  least  change  in  its 
rhythm,  the  least  prolongation  or  roughness  of  its  sounds, 
or  the  slightest  evidence  of  pericardial  friction,  we  are  still 
bound  to  take  such  precautions  as  the  circumstances  of  the 
case  may  seem  to  call  for.  Though  we  may  not  feel  justified, 
without  some  direct  evidence  of  inflammation,  in  having  re- 
course to  active  depletion,  we  shall  yet  do  well  to  put  a  few 
leeches  on  the  chest,  and  commence  the  cautious  administra- 
tion of  mercury,  while  watching  most  jealously  for  anj;-  indi- 
cation which  can  fix  the  seat  and  nature  of  the  disease,  and 
warrant  our  taking  more  active  measures. 

When  the  pericardium  is  affected,  there  is  sometimes,  from 
the  first,  a  distinct  sound  of  friction,  and  then,  however  slight 
the  sound  may  be,  the  evidence  of  mischief  is  unequivocal, 
even  though  there  be  total  absence  of  pain  and  other  gene- 
ral symptoms  of  cardiac  inflammation.  But  it  frequently  hap- 
pens that  the  sound  occasioned  by  exocardial  fiiction  is  at 
first  indistinct,  heard  only  over  a  small  circumscribed  space 
in  the  prgecordial  region,  and  audible  at  one  moment,  inaudi- 
ble at  another.  Thus,  sometimes  for  a  day  or  tAvo  together, 
this  abnormal  sound  will  be  alternately  audible  or  inaudible, 
until  at  length  it  either  becomes  permanent  or  ceases  altogether. 
In  cases  such  as  this,  it  would  not  be  right  to  defer  all  treat- 
ment until  after  the  full  development  of  a  friction-sound, 
neither  would  it  be  expedient  to  adopt  the  active  measures 
required  for  the  arrest  of  wide-spreading  inflammation.     These 


220  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

indistinct  and  indefinite  yet  abnormal  sounds,  so  frequently 
subside  without  any  treatment,  that  their  presence  alone  docs 
not  justify  our  taking  any  vigorous  steps  for  their  removal;  at 
the  same  time  they  are  so  suggestive  of  evil,  and  so  commonly 
prove  the  precursors  of  extensive  mischief,  that  some  precau- 
tionary treatment  should  be  adopted,  and  their  course  nar- 
rowly watched,  in  order  that  the  remedies  may  be  pushed 
more  vigorously  should  their  increase  betoken  active  inflam- 
mation. 

So,  again,  Avith  regard  to  endocardial  disease.  When  a 
murmur,  known  not  to  have  existed  before,  arises  in  the 
course  of  acute  rheumatism,  and  when,  more  especially,  its 
commencement  is  marked  by  praecordial  pain,  by  increase  in 
the  febrile  disturbance,  and  by  fluttering  or  irregularity  in 
the  heart's  action,  then  it  is  to  be  referred  to  commencing 
endocardial  mischief,  and  no  time  should  be  lost  in  employing 
the  full  force  of  our  remedial  agents. 

Sometimes,  however,  no  distinct  murmur  exists,  but  we  may 
distinguish  a  slight  roughness  or  harshness,  or  undue  prolon- 
gation of  the  systolic  sound.  Even  this,  if  accompanied  by 
prsecordial  pain,  dyspnoea,  and  palpitation,  is  sufficient  to 
excite  alarm,  and  to  justify  the  adoption  of  measures  for  its 
subjugation,  inasmuch  as  such  a  symptom  aff'ords  sure  evi- 
dence of  mischief,  and  is  the  usual  forerunner  of  active  in- 
flammation. The  harsh,  or  rough,  or  prolonged  sound  of 
to-day,  is  the  precursor  of  the  systolic  murmur  of  to-morrow. 

At  other  times  old-standing  valvular  disease,  with  its  conse- 
quent old-standing  valvular  murmur,  makes  it  difficult,  if  not 
impossible,  to  determine  by  the  ear  alone,  whether  any  fresh 
inflammation  has  been  set  up.  In  such  a  case  the  activity  of 
the  treatment  must  be  regulated,  in  great  measure,  by  the 
severity  of  the  general  symptoms. 

Not  unfrequently  a  systolic  murmur  arises  which,  from  its 
position  and  the  direction  in  which  it  is  heard,  is  manifestly 
connected  with  imperfect  closure  of  the  mitral  orifice,  yet  is 
unaccompanied  by  prsecordial  pain,  dyspnoea,  or  palpitation, 
or    by    any    formidable    cardiac    symptoms.     In    many    such 


ITS   TREATMENT.  221 

instances  the  irregular  character  and  short  persistence  of  such 
a  murmur,  its  frequent  recurrence,  and  its  ultimate  subsidence 
without  any  treatment  specially  directed  to  its  subjugation, 
has  led  me  to  believe  it  referable  to  temporary  imperfection  of 
the  valvular  apparatus  consequent  on  the  irregular  contrac- 
tion of  the  structures  connected  with  the  valves.  Therefore, 
although  from  the  first  commencement  of  such  a  murmur,  it  is 
always  expedient  to  have  recourse  to  precautionary  treatment, 
such  as  the  administration  of  calomel  and  opium,  it  would 
hardly  be  right  to  bring  the' full  force  of  antiphlogistic  reme- 
dies to  bear,  unless  the  murmur  persists  or  increases  in 
intensity,  or  is  accompanied  by  pain,  irregularity  of  the 
heart's  action,  or  by  some  other  indication  of  organic  cardiac 
mischief. 

Sometimes,  again,  as  I  can  testify  from  repeated  observa- 
tion, an  endocardial  murmur  arises,  in  no  way  connected  with 
inflammatory  action,  but  referable  altogether  to  functional 
causes  ;  and  although  the  superficial  position  of  such  a  mui'- 
mur,  and  the  direction  in  which  it  is  heard,  viz.,  along  the 
track  of  the  pulmonary  artery,  when  coupled  with  the  pale 
exsanguine  appearance,  and  exhausted  condition  of  the  patient, 
serve,  in  most  cases,  to  distinguish  it  from  a  murmur  attribut- 
able to  organic  mischief,  still,  if  considerable  caution  be  not 
observed,  it  may  be  mistaken  for  a  murmur  the  result  of  in- 
flammation, and  treatment  may  be  adopted  ill  suited  to  the 
circumstances  of  the  case. 

The  greatest  care,  then,  is  requisite  in  listening  to  tlie  car- 
diac sounds.  The  heart  should  be  examined  daily,  and  the 
least  deviation  from  health  noted.  The  slightest  prolongation, 
or  unnatural  harshness,  or  roughness  of  its  sounds,  is  sufficient 
to  excite  alarm,  and  the  least  suspicion  of  inflammation  is 
enough  to  justify  some  precautionary  treatment.  But  until 
the  existence  of  inflammation  is  placed  beyond  doubt,  it  is  not 
necessary,  nor  indeed  would  it  be  prudent,  to  push  our  meas- 
ures so  vigorously  as  otherwise  would  be  deemed  essential. 
The  remedies  to  be  employed  are  the  remedies  for  inflamma- 


222  UIIEUMATIC    INFLAMMATION    OF    THE    HEART, 

tion,  but  tliev  should  be  duly  apportioned  to  the  exigencies  of 
the  case. 

There  is  yet  one  point  which  requires  notice  in  connection 
•with  these  endocardial  murmurs.  It  is,  that  during  the  con- 
valescence of  a  patient,  even  after  he  has  risen  from  his  bed. 
and  has  begun  to  walk  about  the  room,  a  valvular  murmur 
will  sometimes  make  its  appearance,  and,  unless  immediately 
attended  to,  will  remain  permanent.  In  these  instances  the 
murmur  itself  affords  the  first  intelligence  of  mischief;  for, 
although  there  generally  exists  some  irritability  about  the 
heart,  there  is  no  pain,  and  no  unusual  palpitation.  Even 
during  convalescence,  then,  the  heart  must  be  constantly  and 
carefully  examined,  and  on  the  first  indication  of  change  in  the 
character  of  its  sounds,  most  active  treatment  must  be  had 
recourse  to ;  treatment  active  not  in  its  essential  character  so 
much  as  in  the  rapidity  with  which  it  is  pushed.  In  these 
cases  there  probably  exists  some  chronic  irritation  of  the  valves, 
and  when  the  rapidity  of  the  circulation  is  subsiding,  fibrin  is 
deposited  just  as  it  often  is  in  the  rheumatic  diathesis,  inde- 
pendently of  any  paroxysm  of  acute  rheumatism,  and  just  as  it 
was  seen  to  be  with  the  gradual  cessation  of  the  circulation  in 
Dr.  Hope's  experiments  on  the  ass.  The  remedies  most  poAv- 
erful  in  preventing  its  further  deposition,  and  in  effecting  its 
removal,  are  alkalies  and  the  neutral  salts,  with  opium,  in  full 
doses,  and  niercur}^,  cautiously  administered. 

In  every  instance  in  which,  after  all  active  symptoms  have 
subsided,  there  still  remains  much  irritability  of  the  heart,  it  is 
expedient,  while  attending  to  the  general  health,  to  administer 
occasional  doses  of  opium  and  digitalis,  and  to  apply  an  opium 
or  a  belladonna  plaster  to  the  chest.  By  such  precautionary 
measures,  and  by  enforcing  that  rest  which  is  necessary  to 
enable  the  excited  heart  to  recover  itself  and  reassume  its 
natural  mode  of  action,  we  may  guard,  in  great  measure, 
against  those  lesions  which,  arising  after  all  inflammatory 
action  has  been  subdued,  are  due  to  the  existence  of  chronic 
irritation  rather  than  of  true  inflammation. 

The  following  cases  will  serve  as  illustrations  of  the  treat- 


CASES    ILLUSTRATING    ITS    TREATMENT.  223 

ment  recommended,  smU  of  thfe  share  ■which  each  remedy  takes 
in  effecting  the  cure. 

Case  I.^ — Fanny  Nicholls^  ^^i  pale-faced  girl,  j^et.  19,  -was 
admitted  into  ^liie  Queen's  Ward  of  St.  George's  Hospital,  on 
the  31st  of  December,  1850.  She  had  been  attacked,  on 
Christmas  Day,  with  redness  and  swelling  of  the  joints,  and  all 
the  usual  symptoms  of  rheumatic  fever.  On  admission  into  the 
hospital  these  symptoms  continued  Avith  increased  severity. 
The  sounds  of  the  heart  were  clear ;  but  as  she  complained  of 
pain  in  the  prsecordial  region,  it  was  judged  expedient  to  put 
her  under  the  influence  of  mercury,  and  the  following  pill  was 
therefore  ordered  : 

I^.     Hydrarg}-ri  Cliloridi,  gr.  iij  ;    Opii,  gr.  j.     M.  ft.      Pilula   G''^   boris 
sumenda. 

January  Xat. — The  next  day  the  sounds  of  the  heart  still 
remained  clear,  and  there  was  no  increased  dullness  on  percus- 
sion in  the  precordial  region,  but  she  complained,  as  before, 
of  pain  in  the  chest,  and  the  pulse  was  120  and  stronger ;  so 
it  was  judged  advisable  to  7-epeat  the  pill  every  four  hours,  and 
to  give  her  a  saline  effervescing  draught  with  gr.  xv  of  Nitrate 
of  Potash. 

So  she  went  on  until  the  4th  instant.  Day  by  day  her 
heart  was  carefully  examined,  but  on  no  occasion  could  any 
evidence  of  mischief  be  obtained.  My  friend  and  colleague. 
Dr.  Bence  Jones,  under  whose  treatment  she  had  been  placed, 
was  now  called  away  from  town,  and  she  was  transferred  to  my 
care.  Early  in  the  morning  her  chest  had  been  examined,  and 
the  heart's  sounds  reported  free  from  murmur ;  but  when  I 
first  saw  her  in  the  afternoon  she  was  complaining  of  increased 
pain  in  the  cardiac  region,  and  an  incipient  exocardial  friction- 
sound  was  audible  at  the  base  of  the  heart,  and  a  slight  systolic 
murmur  at  the  apex.      There  was,  as  yet,  no  extension  of  the 

1  This  is  the  only  case  in  which  I  have  ever  known  extensive  pericarditis 
subdued  and  the  friction-sound  got  rid  of,  within  six  days  from  the  date  of  its 
commencement.  Such  a  speedy  termination  of  the  disease  cannot  usually  he 
brought  about  even  by  the  most  judicious  treatment. 


224  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

natural  praecordial  dullness.  Her  joints  were  still  red  and 
swollen ;  the  gums  were  unaffected  by  the  mercury.  Pulse 
120,  full,  and  somewhat  irregular,  skin  perspiring  freely, 
tongue  furred,  and  bowels  confined.  Urine  reported  scanty 
and  turbid,  but  none  had  been  saved  for  examination.  The 
inflamed  joints  were  wrapped  up  in  flannels  soaked  in  an  alka- 
line and  opiate  fomentation,  and  as  she  did  not  appear  to  be 
ver}'  susceptible  of  the  influence  of  mercury,  I  ordered  a  drachm 
of  the  Mercurial  ointment  to  be  rubbed  in  night  and  morning, 
on  the  chest,  and  the  Calomel  and  Opium  pill  to  be  repeated 
every  four  hours,  as  before.  The  following  draught  was  also 
ordered  to  be  taken  between  each  dose  of  the  pills : 

I^.     Haust.  Salinus  efFervescens  c.  Potassa^  Xitratis,  gr.  xv ; 

Sodce  Potassio-Tart.,  3ij  ; 
Tincturae  Opii,  ^x. 

On  the  5th  she  remained  much  the  same.  The  sound  of 
friction  was  not  so  loud  as  on  the  preceding  day,  but  it  had 
become  universally  diffused  over  the  heart,  and  there  was 
increasing  dullness  in  the  pn^cordial  region,  showing  the  exist- 
ence of  effusion  in  the  pericardium.  As  the  gums  were  not 
affected  by  the  mercury,  the  medicines  were  continued  as 
before. 

On  the  6th  she  was  better  in  some  respects.  She  had  slept 
a  little  during  the  night ;  her  pulse  had  fallen  to  104 ;  the 
urine,  though  still  extremely  acid  and  turbid,  was  more 
abundant,  and  her  joints  were  far  less  painful.  Nevertheless, 
the  exocardial  friction-sound  Avas  very  loud,  and  the  pme- 
cordial  dullness  more  extended ;  so  a  large  blister  was  ordered 
to  be  placed  over  the  heart ;  the  Calomel  and  the  Mercurial 
inunction  were  continued  as  before,  and  ten  minims  of  the 
Vinum  Colchici  were  added  to  the  draught.  This  I  thought 
likely  to  prove  serviceable  from  its  diuretic  no  less  than  from 
its  antirheumatic  properties. 

On  the  Tth  there  was  very  little  alteration  in  her  symptoms, 
except  that  the  ui'ine  had  become  abundant  and  almost  clear, 
sp.  gr.  1026,  and  the  bowels  showed  a  tendency  to  relaxation. 
The  blister  had  risen  well  and  was  discharging  freely.     The 


CASES    ILLUSTRATING    ITS   TREATMENT.  225 

gums  were  still  unaffected  by  the  mercury,  but  as  the  bowels 
were  becoming  irritable,  the  inunction  was  discontinued,  and 
fifteen  minims  of  the  Tr.  Opii  were  given  with  each  dose  of  the 
medicine.     The  pills  were  repeated  as  before. 

On  the  8tli  there  was  manifest  improvement.  She  had  slept 
about  two  hours  during  the  night ;  her  pulse  had  fallen  to  80,  and 
the  urine  continued  clear,  abundant,  sp.  gr.  1025.  The  blister 
was  still  discharging  freely;  there  was  less  extended  dullness 
in  the  region  of  the  heart,  and  the  friction-sound,  though  still 
loud  at  the  base  of  the  heart,  was  no  longer  audible  at  the 
apex.  There  was  still  a  slight  tendency  to  diarrhoea,  but  as 
the  gums  were  unaifected,  the  pills  and  the  draught  were  con- 
tinued as  before. 

On  the  9th  the  favorable  progress  of  the  disease  was  more 
marked.  The  dullness  on  percussion  in  the  prjecordial  region 
was  now  scarcely  more  extended  than  natural,  and  the  friction- 
sound  was  confined  to  the  base  of  the  heart.  The  systolic 
bellows-sound  had  quite  disappeared.  The  relaxation  of  the 
bowels  still  continued,  though  not  to  a  distressing  extent;  so, 
as  the  mouth  was  as  yet  unaffected  by  the  mercury,  the  pills 
and  draught  were  repeated. 

On  the  10th  the  inflammation  of  the  heart  was  subdued. 
There  was  no  longer  any  extension  of  the  prsecordial  dullness, 
and  no  longer  any  friction-sound  or  endocardial  murmur.  The 
pulse  Avas  84,  soft;  the  urine  clear  and  abundant,  and  the 
tongue  much  cleaner.  There  was  neither  redness  nor  tender- 
ness of  the  gums,  but  the  relaxation  of  the  bowels  had  in- 
creased, and  the  diarrhoea  was  evidently  due  to  mercurial  action, 
so  I  ordered  her  to  omit  the  pills.  The  draught  was  continued 
as  before,  and  a  pill  was  given  at  bedtime,  containing  three 
grains  of  calomel  and  two  of  opium. 

On  the  11th,  the  diarrhoea  still  continuing,  the  dose  of 
potassio-tartrate  of  soda  was  reduced  to  a  drachm ;  and  on  the 
13th,  as  her  aspect  was  greatly  improved,  the  pulse  quiet,  the 
tongue  moist  and  almost  clean,  the  salines  were  omitted,  and 
a  quinine  draught  was  administered  twice  a  day,  Avhile  her 
bowels  were  quieted  by  Dover's  powder.     From  this  time  her 


226  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

convalescence  proceeded  steadily;  and  Avhen  she  left  the  house, 
on  the  5th  of  February,  her  heart  was  acting  regularly  and  its 
sounds  were  clear  and  free  from  murmur. 


Case  II. — Sarah  Cowley,  set.  23,  was  admitted  into  the 
Rosebery  "Ward  of  St.  George's  Hospital,  on  the  8th  of  August, 
1851,  laboring  under  acute  rheumatism  of  nine  days'  duration. 
She  had  undergone  an  acute  attack  of  tlie  disease  four  years 
ago,  but  from  that  time  had  remained  free  from  pain  until  the 
commencement  of  the  present  illness.  On  admission,  her  left 
hand,  right  knee,  and  ankle  were  exquisitely  painful,  and  were 
red,  swollen,  and  inflamed;  skin  hot,  but  not  perspiring;  tongue 
yellowish,  furred,  and  somewhat  dr}^;  bowels  open ;  urine  scanty 
and  strong  smelling,  high  colored,  and  loaded  with  the  lithates, 
sp.  gr.  1020 ;  saliva  acid.  The  menstrual  periods  were  reported 
regular.  Her  countenance  was  anxious;  the  breathing  short 
and  catching;  and  she  complained  of  much  pain  in  the  region 
of  the  heart.  Not  the  slightest  evidence  of  exocardial  friction 
could  be  detected ;  but  a  loud,  harsh  murmur,  heard  loudest  at 
the  apex  of  the  heart,  accompanied  and  almost  overpowered 
the  first  sound  of  the  heart.  The  pulse  was  100,  somewhat 
hard  and  irregular. 

The  inflamed  joints  were  fomented  as  usual,  and  the  follow- 
ing remedies  were  prescribed: 

Ilirudines  x,  region!  cordis. 
^.  Hydr  Chloridi,  gr.  iij ;  Opii,gr.  j.  M.  ft.  Pilula,  4"»  quAque  borA  sumenda. 

Haustiis  Potassic  Xitratis,  5JSS  ;  Sodie  Potiissio-Tarl.,  5'j  j  ^'i°i  Colchici, 
Ti\xv;  Tiact.  Opii,  ^n^iij- 

M.  ft.  Haustus  4'"'  boris  alternis  sumendus. 
Fever  diet. 

9th. — She  dozed  at  intervals  during  the  night,  and  perspired 
freely.  The  next  day  the  joints  were  much  easier,  and  the 
urine  more  abundant;  sp.  gr.  1028.  The  heart's  sounds,  how- 
ever, were  much  the  same,  and  there  was  still  some  pain  at  the 
heart.  The  pulse  was  100,  the  tongue  coated,  and  somewhat 
dry,  and  the  bowels  rather  relaxed. 


CASES    ILLUSTRATING    ITS   TREATMENT.  227 

Rep.  Hirudines  vj.  regioni  cordis. 

Repetatur  Pilula  4''^  horis. 
Rep.  Haustus  4'''*  horis  alternis,  sod  c.  Tincturffi  Opii,  TiXxv. 

10th. — Dozed  at  intervals  throughout  the  night,  and  is  much 
better  this  morning.  Has  no  longer  any  redness  or  swelling 
of  the  joints,  or  any  pain  in  the  chest  except  after  exertion,  as 
from  turning  in  bed.  Systolic  murmur  still  present,  but  less 
loud  and  harsh.  Perspires  freely.  Pupils  rather  contracted. 
Tongue  coated.  Bowels  much  relaxed.  No  urine  had  been 
saved  for  examination,  but  it  was  reported  free  and  no  longer 
turbid.     Gums  not  affected. 

As  the  force  of  the  disease  was  evidently  checked,  and  the 
opium,  though  given  in  sufficient  quantity  to  cause  contraction 
of  the  pupils,  had  failed  to  restrain  the  purgative  action  of  the 
mercury,  and  to  allay  the  irritation  to  which  it  gave  rise,  the 
pills  were  repeated  only  twice  a  day.  The  draught  was  con- 
tinued as  before. 

lltJi. — She  passed  a  better  night,  and  the  next  day  reported 
herself  almost  free  from  pain.  She  was  perspiring  freely. 
Gums  becoming  red,  swollen,  and  tender.  Bowels  much  re- 
laxed. No  urine  saved  for  examination,  but  reported  abundant 
and  clear.  Pulse  116,  weak  and  irritable.  A  systolic  murmur 
still  perceptible,  though  less  loud  and  harsh  than  it  was  yes- 
terday. 

As  the  rheumatic  symptoms  were  now  almost  subdued,  the 
pills  and  draught  were  omitted,  and  a  grain  of  opium  was  given 
every  six  hours.     The  next  day — 

12^A. — As  the  skin  was  becoming  sodden,  a  quinine  draught, 
with  a  few  minims  of  the  dilute  sulphuric  acid,  was  ordered  to 
be  taken  twice  a  day;  and,  as  the  bowels  had  not  been  relieved, 
3SS  of  the  sulphate  of  magnesia  was  added.  x\t  the  same  time, 
by  way  of  precaution  against  a  relapse,  a  pill  was  given  at 
night,  containing  a  grain  of  opium  and  two  grains  of  the  acetous 
extract  of  colchicum. 

From  this  time  she  improved  daily.  By  the  14th  she  had 
no  longer  any  pain,  the  heart's  action  was  much  quieter,  and 
the  murmur  softer.    On  the  16th  she  was  so  much  more  tranquil, 


228  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

and  all  her  symptoms  showed  such  decided  improvement,  that 
I  deemed  it  unnecessary  to  continue  the  pill,  and  therefore 
ordered  her  to  take  the  quinine  draught  only.  By  the  18th 
the  murmur  had  become  so  faint,  that  at  times  the  ear  almost 
failed  to  appreciate  it,  and  in  other  respects  she  was  conva- 
lescent. However,  as  she  was  very  pale,  five  grains  of  the 
Pilula  Ferri  co.  were  given  three  times  a  day,  in  addition  to 
the  quinine;  and  this  she  continued  taking  up  to  the  3d  of 
September,  when  she  left  the  house,  her  health  being  com- 
pletely re-established.  A  slight  systolic  mitral  murmur,  how- 
ever, still  existed. 


Case  III. — Harriet  Pope,  a  pasty-faced  girl,  set.  17,  was 
admitted  into  the  Princess  AVard  of  St.  George's  Hospital  on 
the  3d  of  September,  1851,  suffering  from  acute  rheumatism. 
The  present  was  her  first  attack.  It  began  five  days  before 
admission,  with  pain,  heat,  redness,  and  swelling  of  the  feet, 
ankles,  and  the  left  knee ;  but  when  I  first  saw  her  in  the  hos- 
pital, the  feet  and  ankles  alone  were  affected.  She  was 
perspiring  freely ;  tongue  coated  and  white  ;  urine  acid,  high 
colored,  and  rather  scanty,  sp.  gr.  1014;  bowels  reported  open; 
pulse  130,  weak  but  regular.  She  had  no  pain  in  the  region  of 
the  heart,  nor  was  there  any  extension  of  the  prjecordial  dull- 
ness ;  but  there  was  a  slight  roughness  with  the  first  sound  at 
the  apex  of  the  heart,  and  an  indistinct  irregular  double  mur- 
mur, which  gave  the  idea  of  a  commencing  exocardial  friction- 
sound  at  the  base  of  the  heart. 

I  ordered  eight  leeches  to  be  applied  to  the  region  of  the 
heart,  the  inflamed  joints  to  be  fomented  as  usual,  and  pre- 
scribed the  following : 

I^.  Hydrarg3Ti  Chloridi,  gr.  iij ;  Opii,  gr.  j,  ter  in  die. 

Hiiustus  SenniTJ  c.  SodiU  Potassio-Tart.,  5iv,  eras  mane. 

Haust.  Potassix)  Citratis,  §is9  ; 

Sodae  Potassio-Tartratis,  5ij ; 

Vini  Colchici,  "nj^xv; 

Liq.  Opii  Sed    (Battlei),  lt|.viij ;  G"'  quaque  bora. 

Sept.  4th. — The  next  day  she  was  decidedly  worse.     The 


CASES    ILLUSTRATING    ITS    TREATMENT.  229 

pains  in  the  joints  were  easier,  but  she  had  not  slept ;  her 
countenance  was  anxious,  the  pulse  140,  extremely  weak, 
irregular,  and  occasionally  intermittent,  and  she  exhibited 
extreme  disinclination  to  change  her  posture.  There  was  still 
no  pain  at  the  heart,  but  extended  dullness  on  percussion  in  the 
prgecordial  region,  with  great  obscurity  and  distance  of  the 
heart's  sounds,  showed  that  effusion  into  the  pericardium  had 
taken  place  with  unusual  rapidity.  A  distinct  exocardial  fric- 
tion-sound could  be  heard  now  and  then  at  the  base  of  the  heart. 
The  bowels  had  acted  twice-  after  the  Senna  ;  the  tongue  was 
furred,  but  moist.  No  urine  had  been  saved  for  examination  ; 
it  was  reported  scanty. 

Hirudines  xij,  region!  cordis  et  postea  emplastrum  Cantbaridis. 
Repetatur  pilula  6''^  horis. 
Repetatur  haustus  G^'^  horis  alternis. 

5th — The  next  day  there  were  signs  of  amendment.  She  had 
slept  fairly  ;  the  pains  in  the  joints  were  slight,  and  the  swell- 
ing had  entirely  disappeared ;  the  pulse  had  fallen  to  120,  and 
was  much  more  regular ;  the  praecordial  dullness  was  less 
extended  ;  the  sounds  of  the  heart  were  less  distant,  showing 
absorption  of  the  fluid  in  the  pericardium  ;  and  a  loud  to-and- 
fro  sound  of  friction  was  now  audible  over  the  entire  surface  of 
the  heart.  The  countenance,  however,  was  still  distressed  and 
anxious.  She  was  perspiring  freely.  The  urine  was  reported 
to  have  been  passed  in  much  larger  quantity  :  a  small  quantity 
which  had  been  saved  had  a  sp.  gr.  of  1028. 

Repetantur  Medicanienta. 

6tJi. — She  passed  a  restless  night,  and  the  next  day  exhib- 
ited more  anxiety  of  countenance,  and  in  many  respects  a 
material  aggravation  of  her  symptoms.  She  now,  for  the  first 
time,  complained  of  pain  at  the  heart,  and  of  dyspnoea,  with 
occasional  cough  ;  there  was  sonorous  rhonchus  all  over  the 
chest ;  the  heart's  sounds  were  again  more  obscured ;  the  prge- 
cordial  dullness  had  again  extended  itself;  and  the  pulse  Avas 
120,  and  irregular.  The  skin  was  hot  and  perspiring  ;  but  the 
discharge  from  the  blister  had  almost  ceased. 

Repetatur  emplastrum  Cantharidis  regioni  cordis. 
Perstet  in  usu  Medicamentorura. 


230  RHEUMATIC    INFLAMMATION    OF    THE    HEART, 

ItJi. — The  following  day  the  pain  at  the  heart  continued,  and 
the  increase  of  eifusion  was  manifested  by  the  total  cessation  of 
the  friction-sound,  by  the  distance  and  feebleness  of  the  heart's 
sounds,  which  had  become  almost  inaudible,  and  by  the  dullness 
on  percussion  which  now  extended  over  to  the  right  side  of  the 
sternum.  Her  countenance  was  very  anxious ;  the  pulse,  how- 
ever, had  fallen  to  100,  and,  though  feeble,  was  tolerably  steady ; 
the  bowels  had  acted  once  comfortably ;  and  she  had  no  longer 
any  pains  in  the  joints.  No  urine  had  been  saved,  but  it  was 
reported  tolerably  abundant.  The  gums  were  not  affected,  so 
mercurial  ointment  was  applied  to  the  blistered  surface,  the  pill 
was  repeated  every  six  hours,  as  before,  and  a  diuretic  draught, 
containing  Potassee  Nitratis,  gr.  x,  Tr.  ScilljB,  "ixv,  Tr.  Can- 
tharidis  tt^xx,  was  substituted  for  the  saline  medicine  she  had 
hitherto  taken. 

^th. — The  next  day  mercurial  action  was  more  decided,  and 
she  was  manifestly  better.  Her  countenance  was  less  anxious  ; 
the  extent  of  dullness  on  percussion  had  diminished,  the  friction- 
sound  was  again  audible,  the  sounds  of  the  heart  were  loud,  and 
the  pulse  had  fallen  to  96.    The  bowels  were  somewhat  relaxed. 

Perstet  in  nsu  hausti'is  diuretici. 

Repetatur  pilula  bis  in  die  tantura. 

Opii,  gr.  j,  liora  soinni. 

S}th. — Cojitinucd  improvement.  Gums  fully  affected.  Sounds 
of  the  heart  clearer,  and  friction-sound  very  loud.  Less 
extension  of  the  natural  priecordial  dullness.  Pulse  90,  regu- 
lar.    Bowels  much  relaxed,  with  green  mercurial  motions. 

Perstet  in  usu  haustus  diuretici. 

Omittantur  pilulae. 

Opii,  gr.  j,  bis  in  die. 

From  this  time  her  improvement  was  steady  and  progressive. 
On  the  12th  I  thought  it  expedient  to  apply  another  blister  on 
the  chest,  with  the  view  of  accelerating  the  absorption  of  the 
matters  effused  into  the  pericardium,  but  with  this  exception, 
no  alteration  was  made  in  the  treatment  until  the  4th  of  Octo- 
ber, when,  as  the  endocardial  murmur  was  no  longer  audible, 
and  the  pulse  was  weak,  a  drachm  of  the  Tinct.  Cinchonae  was 


CASES    ILLUSTRATING    ITS    TREATMENT.  231 

added  to  the  draught.  When  she  was  able  to  move  easily  in  bed 
and  shift  her  position,  so  as  to  submit  to  a  careful  stethoscopic 
examination,  some  little  dullness  was  discovered  at  the  base  of 
the  right  lung  posteriorly,  and  legophony  was  also  audible 
there  ;  but  as  there  was  no  pain  on  inspiration,  no  distress  of 
breathing,  and  no  quickness  or  sharpness  of  the  pulse  indica- 
ting existing  inflammation,  no  treatment  was  specially  directed 
to  it,  but  the  diuretic  mixture  was  continued  as  before.  By  the 
9th  of  October  the  segophony  had  disappeared,  healthy  respi- 
ration was  re-established  throughout  the  chest,  and  the  heart's 
sounds  were  clear  and  free  from  murmur,  so  the  diuretics  were 
omitted,  and  a  quinine  draught  ordered.  This  she  continued 
taking  until  the  21st  instant,  when  she  left  the  hospital ;  the 
heart's  action  being  regular,  its  sounds  perfectly  free  from 
murmur,  and  the  respiration  natural. 


Case  IV. — On  the  19th  of  January,  1847,  I  was  asked  to 
see  Master  F.  0 — ,  set.  8,  who  had  been  seized  that  morning 
by  acute  pain  in  the  right  elbow  and  the  left  shoulder,  and  on 
the  left  side  of  the  chest.  The  pain  attacked  him  suddenly, 
without  rigors  or  any  previous  warning.  He  was  unable  to 
bend  his  right  arm,  or  to  raise  the  left  arm  to  his  head,  and 
could  not  bear  pressure  on  either  of  the  affected  joints  or  on 
the  peetoralis  major.  Skin  hot  and  perspiring.  Tongue  fur- 
red. Bowels  costive.  Urine  loaded.  Pulse  130,  rather  sharp. 
Heart's  sounds  free  from  murmur.  Perspiration  free.  Five 
grains  of  Calomel,  followed  by  a  black  draught,  aided  by 
some  saline  medicine,  with  ten  grains  of  Niter,  fifteen  minims 
of  Colchicum  Wine,  and  fifteen  minims  of  the  Vinum  Antimo- 
niale,  got  rid  of  the  pains  within  twenty-four  hours,  and  I  saw 
nothing  more  of  him  until  tlie  24th,  when  I  was  again  asked 
to  see  him.  He  was  then  complaining  of  faintness,  with  pal- 
pitation and  a  stabbing  pain  under  the  left  breast.  This  pain 
was  increased  by  pressure  under  the  ribs  on  the  left  side,  as 
also  by  the  effort  of  coughing.     There  was  no  pleuritic  fric- 


232  RHEUMATIC    INFLAMMATION    OF   THE    HEART, 

tion  nor  fegopliony,  nor  were  there  any  of  tlie  fine  crepita- 
tions of  pneumonia,  but  a  loud  to-and-fro  sound  of  friction 
was  audible  over  the  whole  of  the  cardiac  region.  There  were 
now  no  pains  in  the  limbs.  Skin  hot  and  perspiring,  the  per- 
spiration having  the  pecnliarly  sour  odor  of  rheumatism. 
Tongue  very  furred.  Bowels  open.  Urine  turbid  and  scanty. 
Pulse  120,  sharp,  irregular,  and  occasionally  intermittent. 

Eight  leeches  were  placed  at  once  over  the  heart,  and  were 
followed  by  a  large  blister ;  and  the  following  medicine  was 
prescribed : 

I^.     Hydrargyri  Chloridi,  gr.  iij ; 

Opii,  gr.  ss.     M.  ft.  Pilula  4"^  horis  sumenda. 

Haustus  Salini  ex  Ammonia,  ^jss  ; 

Potassae  Nitratis,  gr.  x ; 

Potassaj  Tartratis,  5ss ; 

Villi  Colchici,  ^viij.     M   ft.  Haustus  4"^  horis  altemis  sumendus. 

iQth. — Dozed  during  the  night,  and  is  much  as  he  was  yes- 
terday. Tlie  blister  rose  well,  but  the  friction-sound  has 
ceased,  the  heart's  sounds  have  become  feeble,  distant,  and 
muffled,  and  there  is  extended  dullness  on  percussion  in  the 
cardiac  region.     Evinces  a  tendency  to  faint. 

Repetantur  piluUB  et  haustus  4"'*  horis. 
Unguentum  Hydrargyri  parti  vesicatte. 

26^7i. —  No  return  of  friction-sound.  Further  extension  of 
prgecordial  dullness.  Is  very  irritable.  In  other  respects 
much  as  yesterday.     No  mercurial  action. 

Repetantur  medicaraenta  4'*  quaque  hora. 
Rep.  emplast.  Cantharidis  region!  cordis. 
I^.     Pulv.  Ipecacuanh;e  co.,  gr.  v,  hora  somni. 

Ilth. — Slept  fairly.  The  blister  rose  well,  and  to-day  there 
Is  considerable  improvement.  Less  extended  dullness  in  the 
precordial  region.  Friction-sound  again  audible  over  the 
whole  extent  of  the  heart,  and  the  sounds  of  the  heart  much 

louder. 

Rcpetatur  piluhi  sextis  horis. 
Perstct  in  usu  haustus,  sed  adde  Tr.  Scillie,  Ti|xl,  Tr.  Cantharidis,  tt^xx. 

During  the  next  four  days  a  gradual  improvement  was  per- 
ceptible ;  the  heart's  sounds  became  clearer  and  louder ;  the 


CASES    ILLUSTRATING    ITS    TREATMENT.  233 

dullness  on  percussion  decreased  ;  the  urine  increased  in  quan- 
tity, and  the  tendency  to  faintness  ceased ;  the  friction-sound, 
however,  continued,  and  was  heard  over  the  whole  heart,  and 
the  system  gave  no  token  of  being  affected  by  the  mercury. 

On  the  1st  of  February,  contrary  to  my  express  injunc- 
tions, he  had  been  allowed  to  see  and  talk  to  some  of  his 
friends,  sit  up  in  bed,  and  otherwise  exert  himself,  and  when 
I  visited  him  in  the  evening  his  symptoms  were  materially 
aggravated.  The  pulse,  which  for  the  last  five  days  had  aver- 
aged 100,  had  again  risen  to  130  ;  the  heart's  sounds  were  less 
clear,  and  the  dullness  in  the  mammary  region  had  increased. 
There  was  as  yet  no  evidence  of  mercurial  action,  so  the  pills 
and  draughts  were  repeated  every  six  hours,  as  before,  and 
another  blister  was  applied  to  the  chest.  The  bowels  being 
somewhat  confined,  a  senna  draught  was  administered. 

The  beneficial  influence  of  the  blister  was  soon  displayed,  in 
the  increased  steadiness  of  the  heart's  action,  and  the  clear- 
ness of  its  sounds ;  and,  by  the  5th,  the  symptoms  were  much 
the  same  as  before  his  relapse.  The  friction-sound  was  very 
loud,  and  the  prsecordial  dullness  had  greatly  diminished. 
About  this  time  I  had  the  benefit  of  a  consultation  with  Dr. 
Watson,  and,  as  there  was  still  no  mercurial  action,  it  was 
decided  that  the  pills  and  draughts  were  to  be  continued  as 
before.  He  now  slept  well,  and  passed  large  quantities  of 
urine,  and  day  by  day  his  symptoms  betokened  gradual 
amendment.  The  heart's  sounds  became  clearer,  and  the 
friction-sound  less  intense.  The  gums  were  slightly  swollen, 
and  rather  more  red  than  natural,  but  there  W'as  no  mercurial 
fetor,  no  increased  flow  of  saliva,  and  no  evidence  of  full  mer- 
curial action. 

By  the  11th  the  friction-sound  had  disappeared,  so  the  pills 
were  omitted.  On  the  folloAving  day,  as  the  improvement  was 
fully  maintained,  a  draught  was  ordered  to  be  taken  twice  a 
day,  containing  half  a  drachm  of  Nitric  Ether,  eight  grains  of 
Nitrate  of  Potash,  and  an  ounce  of  the  infusion  of  Cascarilla ; 
and,  as  the  action  of  the  heart  was  still  turbulent,  a  bella- 
donna plaster  was  applied  to  the  chest,  and  a  pill  given  every 
16 


234  RHEUMATIC    INFLAMMATION    OF    THE    HEART. 

night  at  bedtime,  containing  half  a  grain  of  powdered  digi- 
talis, a  quarter  of  a  grain  of  opium,  a  grain  of  powdered 
squills,  and  two  grains  of  blue  pill.  Under  this  treatment  he 
improved  rapidly,  and  on  the  20th  it  was  judged  safe  to  omit 
the  medicines  he  had  been  taking,  and  to  give  him  a  quinine 
mixture,  perfect  rest  being  strictly  enforced.  He  continued 
to  take  the  tonic  until  the  28th,  when,  as  the  heart's  action 
was  regular  and  tranquil,  and  his  appetite  good,  the  medicine 
was  discontinued. 

I  have  seen  him  occasionally,  during  the  holidays,  ever 
since  this  attack,  and  the  heart's  sounds  remain  clear,  and  its 
action  regular.  Its  impulse  is  somewhat  stronger  than  natu- 
ral, but  I  cannot  perceive  that  there  has  been  any  material 
increase  in  this  respect  during  the  last  seven  years.  As  yet 
there  has  not  been  the  slightest  recurrence  of  rheumatic 
symptoms. 


CHAPTER  IX. 

ON  THE   STATISTICS  OF   HEART   DISEASE   IN   CONNECTION 
WITH  RHEUMATISM. 

The  statistics  of  heart  disease  in  connection  with  rheumatism 
form  a  subject  deserving  of  attentive  study,  not  only  on  account 
of  their  practical  importance  to  the  physician  who  is  ca;lled 
upon  to  prognosticate  as  to  the  favorable  or  unfavorable  issue 
of  his  patient's  malady,  but  as  tending  to  elucidate  several 
important  matters  on  which  much  loose  speculation  has  been 
hazarded.  That  inflammation  of  the  heart,  or,  as  it  is  com- 
monly designated,  "rheumatism  of  the  heart,"  is  a,  frequent 
accompaniment  of  rheumatic  disease,  and  forms  a,  fearful  addi- 
tion to  articular  pain  and  inflammation,  has,  alas!  been  fully 
verified  by  thousands  who,  sooner  or  later,  have  fallen  victims 
to  its  ravages.  But  the  probability  of  its  occurrence  in  any 
particular  instance,  the  age  and  sex  of  its  victims,  the  form  of 
rheumatism  in  which,  and  the  stage  of  the  disease  at  which  its 
invasion  is  most  to  be  dreaded,  the  relative  frequency  of  the 
difi'erent  forms  which  it  assumes,  and  the  eff"ect  of  remedies  in 
warding  ofi"  its  attacks, — these  are  points  on  which  the  number 
of  observations  hitherto  recorded  are  insufficient  to  warrant 
our  speaking  with  certainty.  Dr.  Latham,  Dr.  Taylor,  and 
other  inquirers  have  done  much  toward  clearing  up  existing 
doubts  on  some  of  these  matters,  but  no  one  can  feel  satisfied 
on  a  subject  of  so  much  importance  until  their  results  have 
been  verified  by  further  investigation. 

Much  difficulty  has  occurred  to  me,  in  instituting  a  com- 
parison between  the  result  of  my  experience  at  St.  George's 
Hospital  and  that  which  others  have  put  on  record,  from  the 
fact  that  a  wide  diff'erence  exists  between  the  grounds  which 
have  been  chosen  as  the  foundation  of  the  various  calculations. 
Some  persons,  for  instance,  in  dividing  febrile  rheumatism  into 


236  STATISTICS    OF    HEART    DISEASE 

an  acute  and  a  subacute  class,  have  included  many  cases  in 
the  former,  which  others  would  have  placed  in  the  latter;  and 
some  have  arranged  in  their  subacute  class  many  cases  which 
others  would  have  denominated  chronic.  Some  have  been 
guided  in  their  classification  solely  by  the  intensity  of  the 
articular  inflammation ;  some  by  the  severity  of  the  febrile 
paroxysms;  while  others,  taking  the  mixed  indication  afforded 
by  the  fever  and  the  articular  pain  and  inflammation,  have 
arranged  and  classified  their  cases  accordingly.  Hence  one 
fertile  source  of  uncertainty  and  confusion.  Judging  from  my 
observation  of  the  nomenclature  adopted  at  several  of  our 
larger  public  institutions,  I  believe  that  cases  are  often  termed 
"acute,"  which  I  should  denominate  "subacute;"  I  have  there- 
fore discriminated,  in  separate  tables,  between  the  undoubtedly 
acute  cases,  and  those  which,  as  marked  by  less  violent  symp- 
toms, may  be  regarded  as  instances  of  less  active  disease.^ 

Another  productive  source  of  error  is  the  great  variation  in 
the  mode  in  wliicli  the  diff"ercnt  classes  of  cases  have  been 
grouped  for   the   purpose   of  examination.      Nothing   can  be 

'  [Jnder  the  head  of  Acute  Rheumatism,  I  have  classed  all  cases  io  which 
the  febrile  paroxysm  has  been  "acute,"  and  accompanied  by  the  profuse  acid 
perspirations,  which  are  eminently  characteristic  of  the  acute  disease ;  while 
under  the  head  of  "subacute,"  I  have  arranged  all  cases  in  which  the  fever 
has  assumed  a  milder  form,  and  the  articular  symptoms  have  been  less  acute, 
though  marked,  perhaps,  by  pain,  and  redness,  and  swelling.  Cases  which 
have  not  been  attended  by  a  well-marked  febrile  movement,  even  though  ac- 
companied by  cedematous  fullness  about  the  joint,  or  by  slight  effusion  within 
the  capsule,  I  have  placed  under  the  head  of  "  chronic."  In  making  this 
division,  I  have  allowed  myself  to  be  guided  by  the  amount  of  the  fever,  rather 
than  by  the  severity  of  the  articular  inflammation,  under  the  belief  that  the 
fever  and  the  arthritis,  carditis,  pneumonia,  pleurisy,  and  other  local  symptoms 
which  often  accompany  the  acute  form  of  rheumatism,  are  the  results  of  one 
common  cause,  and  that  the  fever  affords  a  more  certain  indication  of  the 
amount  of  poison  present  in  the  system,  than  does  the  arthritis,  which  experi- 
ence has  shown  to  be  sometimes  absent,  even  when  the  fever  is  very  severe, 
and  attended  by  acute  inflammation  of  the  heart.  Moreover,  the  conviction 
has  been  forced  upon  me,  that  the  extent  and  number  of  the  internal  compli- 
cations bear  a  more  constant  relation  to  the  amount  of  febrile  movement  than 
to  the  number  and  intensity  of  the  articular  inflammations,  and  that  the  fever 
is  a  fair  exponent  of  the  probability  of  secondpry  affections  in  rheumatism, 
just  as  Louis  has  shown  it  to  be  in  typhoid  fever,  and  many  other  acute  dis- 
orders. 


IN    CONNECTION    WITH    RHEUMATISM.  237 

raore  certain  than  that  the  frequency  of  heart  disease  varies 
greatly,  according  to  the  type  and  severity  of  the  rheumatic 
affection;  and  the  proportion  of  cases  in  which  heart  disease 
is  met  with,  must  vary  therefore  according  as  the  conclusions 
of  different  observers  have  been  drawn  from  acute  or  subacute 
cases,  or  from  both  classes  of  cases  taken  conjointly.  In  some 
instances  on  record,  it  is  stated  that  the  conclusions  have  been 
arrived  at  from  the  examination  of  acute  and  subacute  cases 
taken  indiscriminately:  in  others,  it  is  impossible  to  ascertain 
with  certainty  the  precise  nature  of  the  cases  from  which  the 
recorded  results  have  been  obtained.  The  numbers,  however, 
agree  so  closely  in  some  instances  with  those  obtained  from 
acute  and  subacute  cases  taken  conjointly,  that  I  cannot  help 
thinking  they  must  have  been  deduced  from  a  class  of  cases  in 
which  the  subacute  were  included  with  the  more  acute  examples 
of  the  disease.  Indeed,  I  hope  to  show  that  the  differences 
existing  in  the  very  foundation  of  all  the  subsequent  calcula- 
tions account  for  most  of  the  discrepancies  which  exist  between 
the  reports  of  various  observers. 

The  cases  from  which  my  inferences  are  drawn  are  379  in 
number.  They  embrace  all  the  examples  of  acute  and  subacute 
rheumatism  which  were  admitted  into  St.  George's  Hospital 
under  the  care  of  the  physicians,  during  the  time  I  held  the 
office  of  Medical  Registrar,  namely,  between  the  1st  of  January, 
1845,  and  the  1st  of  May,  1848,  and  include  246  examples  of 
the  disease  in  its  more  acute  form,  and  133  of  a  milder  charac- 
ter. The  heart  was  healthy  in  160  instances;  in  32  I  have  no 
note  of  its  condition,  and  probably,  therefore,  it  was  healthy; 
and  in  187  it  was  either  temporarily  or  permanently  deranged 
to  a  greater  or  less  extent.  Three  tables,  exhibiting  an  analysis 
of  these  cases,  are  appended  to  this  chapter.^ 

Of  the  187  cases  of  heart  disease,  130  were  examples  of 
recent  mischief,^  as  was  evidenced,  either  by  the  supervention 

1  See  pp.  253-50. 

^  It,  must  not  be  understood,  tliat  in  all  these  cases,  the  be.art  was  previously 
free  from  disease,  neither  must  it  be  inferred  that  the  endocardial  murmur 
which  existed,  was  invariably  referable  to  organic  mischief.  These  are  points 
on  v,'hich  positive  information  cannot  usually  be  obtained.    I  only  wish  to  imply^ 


238  STATISTICS    OF    HEART    DISEASE 

of  a  murmur,  after  the  patient's  admission  into  the  hospital, 
or  by  the  existence  of  a  murmur  wliich,  though  present  at  the 
date  of  the  patient's  admission,  was  found  to  subside  toward 
the  close  of  the  disease,  or  was  coincident  with  prgecordial  pain 
and  anguish,  or  with  temporary  irregularity  in  the  heart's 
rhythm ;  in  18  the  date  of  the  mischief  was  doubtful ;  and  in 
39  the  absence  of  inflammatory  symptoms  referable  to  the 
heart,  together  with  the  manifest  enlargement  of  that  organ, 
and  the  little  alteration  which  the  sounds  underwent  during 
the  time  the  patient  was  under  notice,  induced  a  belief  that 
the  disease  was  of  old  standing.  Now,  supposing  that  9  out 
of  the  18  doubtful  cases  were  examples  of  recent  mischief,  and 
9  of  old-standing  disease,  we  get  an  aggregate  number  of  139 
instances  of  recent,  and  48  of  old-standing  cardiac  disease, 
among  379  cases  of  acute  and  subacute  rheumatism  taken  in- 
discriminately. In  other  words,  we  find  that  some  form  of 
heart  affection  existed  in  about  half  the  cases  (1  in  every  2*02) 
of  acute  and  subacute  rheumatism  taken  conjointly;  some  recent 
mischief  in  more  than  one-third,  (1  in  every  2-7,)  and  some  old- 
standing  mischief  in  one  out  of  about  every  eight,  (1  in  every 
7-9.) 

This  is  the  result  when  acute  and  subacute  cases  are  viewed 
collectively;  and  it  is  sufficiently  formidable  in  its  character. 
But  it  assumes  a  still  more  serious  aspect  when  the  acute  are 
separated  from  the  subacute  cases,  and  are  traced  in  their  con- 
nection with  the  cardiac  disease.  Of  the  130  instances  of  recent 
cardiac  mischief,  no  less  than  114  occurred  among  the  class  of 
acute  rheumatism,  as  did  also  10  of  the  doubtful  cases,  and  21 
of  the  cases  of  old-standing  disease,  making  in  all  145  instances  of 

that  in  130  instances,  the  heart  was  implicated  to  a  greater  or  less  extent 
during  the  then  existing  attack  of  rheumatism,  as  was  indicated  by  a  tempo- 
rary or  permanent  exocardial  or  endocardial  murmur.  In  seventeen  cases  the 
prior  existence  of  heart  affection  was  clearly  ascertained,  and  in  several  others 
was  strongly  suspected,  and  in  some,  doubtless,  the  existence  of  a  valvular 
murmur  was  attributable  altogether  to  functional  causes.  Any  attempt,  how- 
ever, to  enumerate  the  cases  in  which  I  believe  the  heart  to  have  been  previ- 
ously affected,  or  the  murmur  to  have  arisen  from  functional  causes,  might 
possibly  lead  to  error,  and  I  have  therefore  abstained  from  hazarding  an  opinion 
ou  either  of  these  points. 


IN    CONNECTION    WITH    RHEUMATISM. 


239 


heart  disease  among  246  examples  of  acute  rheumatism.  Now 
supposing,  as  before,  that  half  the  doubtful  cases  were  instances 
of  recent,  and  half  of  old-standing  gardiac  mischief,  we  find  the 
heart  affected  svith  recent  disease  in  119  instances,  and  with  old- 
standing  disease  in  26  instances,  among  246  patients  afflicted 
with  acute  rheumatism.  In  other  words,  we  find  some  heart 
affection  in  about  three-fifths  (1  in  every  1*7)  of  all  the  cases  ; 
we  get  evidence  of  recent  heart  disease  in  almost  one-half,  (1 
in  every  2*06  ;)  and  of  old-standing  disease  in  about  one  in 
every  nine  and  a  half,  (1  in  every  9*4.) 

On  the  other  hand,  taking  subacute  rheumatism  alone,  a 
remarkable  decrease  is  observed  in  the  proportion  of  cases  in 
which  the  heart  is  afiected  by  pericarditis  and  other  recent 
disease,  and  an  equally  striking  increase  in  the  proportion  of 
old-standing  cardiac  affection.  Among  the  133  patients  suffer- 
ing from  subacute  rheumatism,  there  were  42  instances  of 
cardiac  disease ;  and  of  these,  16  were  examples  of  recent 
affection  of  the  heart;  in  8  the  date  of  the  mischief  was  uncer- 
tain ;  and  in  18  it  was  obviously  of  old  standing.  Dividing 
the  aoubtful  cases  as  before,  we  obtain  20  as  the  aggregate 
number  of  instances  in  which  the  heart  was  recently  affected, 
and  22  as  the  number  in  which  it  was  previously  diseased.  In 
short,  some  form  of  heart  disease  appears  to  accompany  about 
one-third  (1  in  every  3-1)  of  all  cases  of  subacute  rheumatism  ; 
some  recent  heart  affection,  one  in  about  every  six  and  a  half, 
(1  in  every  6*6  ;)  and  some  old-standing  disease,  one  in  every 
six,  (1  in  every  6'04.) 

The  difference  of  these  results  will  be  manifest  from  an  in- 
spection of  the  following  table,  in  which  they  are  collocated 
and  contrasted : 


No.  of  Cases  of 
Rheumatism. 


Acute  and  Subacute,  379 
.     133 


Subacute, 


Acute,       ....     246 


Total  Heart  Disease. 


187,  or  1  in  every  2-02 


42,  or  1  in  every  3  11 
14o,  or  1  in  every  169 


Recent  Heart  Disease. 


139,  or  1  in  every  272 

20,  or  ♦  ill  every  6  6.5 


119,  or  1  in  every  2  06 


Old-standing  Heart 
Disease.^ 


48,  or  1  in  every  7  S9 


22,  or  1  in  every  6-04 
26,  or  1  in  every  9  46 


1  It  must  be  remarked  that  these  numbers  fall  short  of  the  truth  in  regard 
to  the  amount  of  old-standing  heart  disease,  inasmuch  as  the  heart  was  previ- 
ously affected  to  a  greater  or  less  extent  in  several  of  the  cases  in  which  recent 
mischief  occurred. 


240  STATISTICS    OF    HEART    DISEASE 

Thus,  it  would  appear,  that  26'  in  145,  or  1  in  every  5*57 
of  the  cases  of  heart  affection  met  with  in  acute  rheumatism, 
are  of  oUl  standing;  22'  in  42,  or  1  in  every  1'9,  of  those  ac- 
companying the  subacute  form  of  the  disease ;  and  48^  in  187, 
or  1  in  every  3*89,  of  those  discovered  in  acute  and  subacute 
rheumatism,  taken  indiscriminately. 

Taking  these  facts  as  the  foundation  of  my  calculations,  I 
find  that  those  who  have  paid  the  closest  attention  to  the  subject, 
agree  very  nearly  in  fixing  upon  one-half  as  about  the  propor- 
tion of  cases  in  which  cardiac  affection  ordinarily  arises  in  the 
course  of  acute  rheumatism.  It  occurred,  as  has  been  seen,  in 
about  this  proportion  (119  to  246)  among  the  patients  admitted 
into  St.  George's  Hospital.'  Dr.  W.  Budd  met  with  it  in  about 
one-half  (21  in  43)  of  the  cases  which  fell  under  his  observa- 
tion,^ and  M.  Bouillaud  discovered  it  in  about  the  same  propor- 
tion, (65  in  114.)^  Dr.  Latham  has  reported  cardiac  affection 
in  nearly  two-thirds  (90  in  136)  of  his  patients,*  but  as  he 
makes  no  mention  of  old-standing  mischief,  he  probably  includes 
in  his  calculations  all  previously  existing  cardiac  lesions.  If, 
then,  in  accordance  with  the  results  of  my  experience  already 
given,  we  suppose  16,  or  1  in  every  5*57,  of  Dr.  Latham's  cases 
to  have  been  of  old  standing,  the  proportion  is  reduced  to  74  to 
136,  or  to  little  more  than  that  obtained  by  the  authors  before 
referred  to.  Again,  Dr.  Taylor,  of  Huddersfield,  reports  37 
cases  of  heart  affection  among  75  of  his  rheumatic  patients  f 
but  as  this  number  includes  both  recent  and  old-standing  heart 
disease,  and  is  obtained  from  acute  and  subacute  cases,  taken 
indiscriminately,  it  becomes  necessary  to  subject  both  his  num- 
bers to  correction  before  comparing  them  with  the  experience 
of  others.  If,  then,  in  accordance  with  the  results  already 
given,  we  deduct  26,  or  rather  more  than  one-third  of  his  cases, 
(1  in  every  2-8)  as  subacute,  and  suppose  nine  and  a  half,  or  1 
in  every  3*89,  of  his  cases  of  heart  affection  to  be  of  old  stand- 

*  This  number  includes  half  the  cases  of  uncertain  date. 
^  "Library  of  Medicine,"  vol.  v,  p.  195. 

*  "  Traile  Clinique  de  Rheumatisme,"  Preface,  p.  12. 

*  "Clinical  Medicine,"  vol.  i,  p.  143. 

*  '•  Med.-Chir.  Trans.,"  vol.  xxviii,  p.  483. 


IN    CONNECTION   WITH   RHEUMATISM. 


241 


inir,  we  find  that  49  represents  the  number  of  cases  of  acute 
rheumatism,  and  27*5  the  number  of  cases  of  recent  heart  affec- 
tion, a  result  which  tallies  very  closely  with  that  which  has 
been  obtained  by  other  observers.  The  trifling  differences 
existing  between  the  results  of  these  various  observations  are 
exhiliited  in  the  following  table  :^ 


Cases  under  the  care  of 
the  physicians  at  St. 
George's  Hospital    . 

Dr.  Wm.  Budd's  cases 

M.  Bouillaud's  cases   . 

Dr.  Latham's  cases  .  . 

Dr.  John  Taylor's  cases 
Total     .     .     . 

Amount  of  rpcent 
Heart  Aflection. 

Number  of  Cases 

of  Acute 

Rheumatism. 

Proportion  of  Cases  in 
which  recent  Heart 
affection  occurred. 

119 
21 
65 
T4 
27-5 

246 

43 

114 

136 

49 

1  in  every  2-06 
1         "        2-04 
1         "        1-75 
1         "        1-83 
1         "        1-78 

306-5 

588 

1         "        1-91 

A  confirmation  of  these  results  is  obtained  by  an  examination 
of  eleven  cases,  of  which  I  have  collected  notes,  in  which,  from 
the  peculiar  circumstances  attending  them,  no  regular  medical 
treatment  was  adopted.  In  six  of  these,  prsecordial  pain  and 
anguish  were  reported  to  have  existed  at  the  time  of  the  attack, 
and  some  evidence  of  unsoundness  in  the  central  organ  of  the 
circulation  was  manifest  when  the  patients  came  subsequently 
under  my  notice.  Two  of  these  patients  had  previously 
suffered  from  acute  rheumatism,  and  therefore  may  have  had  a 
murmur  dating  from,  and  referable  to,  their  first  attack  :  and  in 
some  of  the  others,  also,  the  murmur  may  have  been  due  to 
previous  disease ;  but  the  symptoms  experienced  in  the  attack 
referred  to,  seem  to  show  that  the  heart  was  then  implicated  in 
the  mischief.  Therefore,  although  these  cases  afford  data  too 
imperfect  to  form  the  groundwork  of  any  accurate  calculation 
as  to  the  frequency  of  carditis,  they  may  serve,  nevertheless, 
to  corroborate  results  obtained  from  more  prolific  sources. 

I  am   thus  induced  to  think  that,  under  ordinary  circum- 

1  In  the  construction  of  this  table  I  have  omitted  Dr.  Macleod's  cases,  which 
are  inserted  elsewhere,  because  he  makes  no  mention  of  the  frequency  of  endo- 
cardial affection,  and  their  quotation,  therefore,  would  only  lead  to  error.  On 
much  the  same  grounds,  no  allusion  is  made  to  Dr.  Basham's  cases. 


242  STATISTICS    OF    HEART    DISEASE 

Stances,  some  heart  aflfection  arises  in  about  half  of  all  cases 
of  acute  rheumatism  ;  but  I  am  persuaded  that,  by  judicious 
treatment,  this  proportion  may  be  very  greatly  reduced. 
Among  168  cases  which  have  come  under  my  care  since  I  first 
commenced  my  present  plan  of  treatment,  the  heart  has  been 
implicated  in  31  cases  only,  and  in  at  least  26  of  these  the 
afi'ection  had  commenced  before  I  saw  the  patient.  This  fact 
is  almost  sufficient  of  itself  to  afford  decisive  evidence  on  the 
subject,  and  to  show  that,  in  most  cases,  the  heart  may  be  pro- 
tected from  mischief  when  the  patient  is  early  subjected  to 
appropriate  treatment.  But  the  evidence  is  even  more  con- 
clusive if  my  earlier  and  less  actively-treated  cases  are  excluded 
from  the  calculation.  For  among  the  last  126  cases  in  which 
the  heart  remained  free  from  inflammation  at  the  time  the 
patients  were  first  brought  under  my  care,  not  a  single  case  of 
endocarditis  or  pericarditis  has  occurred,  the  heart  having  been 
protected  by  the  administration  of  remedies  in  the  manner 
already  pointed  out. 

The  frequency  of  pericarditis  is  a  point  on  Avhich  many 
opposite  conclusions  have  been  arrived  at ;  the  diff'erence,  I 
believe,  resulting,  as  in  the  former  instance,  from  the  variety  of 
the  grounds  chosen  as  the  basis  of  calculation.  Dr.  Macleod' 
reports  its  occurrence  in  more  than  one-fifth  (52  in  226,  or  1 
in  every  4'3,)  of  his  patients  suffering  from  one  variety  of  acute 
rheumatism,  and  in  about  one-sixth  (54  in  307,  or  1  in  every 
5'7,)  of  those  afilicted  with  the  difi'erent  varieties  taken  col- 
lectively; Dr.  Basham^  reports  it  in  about  one-fifth  (14  in  66, 
or  1  in  every  4-7,)  of  those  sufi'ering  from  acute  articular  rheu- 
matism ;   Dr.  Latham^  in  about  one-sixth  (22  in  136,  or  1  in 

'  On  "Rheumatism,"  p.  154. 

^  "  Medico-Chir.  Trans.,"  vol.  xxxii.  Dr.  Basham  has  reported  79  cases  of 
rheumatism,  but  several  of  these  are  cases  of  ''  muscular"  rheumatism,  and  one 
is  called  decidedly  "  chronic  muscular."  In  short,  he  has  reported  only  66  cases 
of  "  acute  arthritic"  rheumatism. 

8  "Clinical  Medicine,"  vol.  i,  p.  144.  Dr.  Latham's  numbers  are  18  in  136, 
but  he  reports  9  cases  in  which  it  was  doubtful  whether  a  murmur  which  ex- 
isted was  referable  to  pericardial  or  endocardial  disease,  and  it  is  therefore 
presumed,  that  4  of  these  9  doubtful  cases  were  instances  of  pericarditis. 


IN    CONNECTION    WITH    RHEUMATISM.  243 

every  6-12  ;)  Dr.  Taylor^  in  about  one-sixth  (8  in  49,  or  1  in 
every  64  ;)  and  I  observed  it  in  about  the  same  proportion 
(39  in  246,  or  1  in  every  6*3, )  among  the  cases  of  acute  rheu- 
matism admitted  into  St.  George's  Hospital.  Dr.  William 
Budd^  met  with  it  less  frequently  in  his  cases  (5  in  43,  or  1  in 
every  8*6  ;)  but  I  have  some  doubts  whether  the  cases  Dr. 
Budd  has  recorded  may  not  include  examples  of  Avhat  I  have 
termed  "  subacute"  rheumatism,  and  if  so,  the  disease  probably 
occurred  in  somewhat  less  than  one-sixth  of  his  acute  cases 
(5  in  28,  or  1  in  every  5'6.) 

An  equally  striking  uniformity  is  apparent  in  the  result  of 
a  strict  examination  into  the  frequency  of  recent  endocardial 
affection.  It  oc(!urred  in  107  of  the  246,  or  in  1  out  of  every 
2*3  of  the  cases  of  acute  rheumatism  already  quoted  as  forming 
the  basis  of  my  calculations  ;^  in  65  out  of  136,  or  in  1  out  of 
every  2-09,  of  Dr.  Latham's  cases  ;*  in  17 "3  out  of  43,  or  in  1 
out  of  every  2-48,  of  Dr.  William  Budd's  cases  f  and  in  25*4 
out  of  49,  or  in  1  out  of  every  1*9,  of  Dr.  Taylor's  cases. ^ 

A  similar  uniformity  is   also  apparent  in  the  result   of  an 

1  "  Mcdico-Chir.  Trans.,"  vol.  xxviii,  p.  483.  Di-.  Taylor's  numbers  are  8  in 
75;  but  he  admits  that  subacute  cases  are  included,  and  about  one-third  of  the 
entire  number  have  therefore  been  deducted  on  that  score. 

2  "  Library  of  Medicine,"  vol.  v. 

3  These  107  cases  are  made  up  thus: — 27  cases  of  endo-pericarditis ;  75  of 
endocardial  affection ;  and  5,  or  half  of  the  cases,  in  which  the  date  of  the 
mischief  was  uncertain.     (See  Table  II,  pp.  254-5.) 

*  Dr.  Latham  reports  18  cases  of  exocardial,  and  74  of  endocardial  affection, 
and  9  in  which  the  seat  of  the  disease  was  doubtful.  Assuming  that  4  of  these 
doubtful  cases  were  examples  of  exocardial  disease,  and  5  of  endocardial  affec- 
tion, we  get  22  cases  of  pericarditis,  and  7'J  of  endocardial  mischief.  The 
number  79,  however,  includes  cases  of  old-standing  cardiac  lesions,  and  on 
this  score,  therefore,  we  must  deduct  IG,  or  1  in  every  5-57  cases.  Hence  the 
numbers  given  above. 

5  Dr.  Wm.  Budd's  numbers  are  21  to  4.3,  but  as  he  makes  no  mention  of 
previously  existing  heart  disease,  it  is  assumed,  in  accordance  with  the  results 
already  given,  that  3  7,  or  1  in  every  5-57,  of  his  cases  were  instances  of  old- 
standing  heart  disease.     Hence  the  numbers  given  above. 

«  Dr.  Taylor's  numbers  are  34  to  75,  but  as  the  number  34  includes  old- 
standing  heart  disease,  and  the  number  7.5  is  obtained  from  acute  and  sub- 
acute cases  taken  collectively,  we  must  deduct  8-G,  or  1  in  every  389,  of  his  34 
cases,  as  instances  of  old-standing  disease,  and  26,  or  1  in  every  2-8,  of  his  75 
cases  as  subacute.     Hence  the  numbers  given  ;ibove. 


244 


STATISTICS    OF    HEART    DISEASE 


examination  into  the  relative  frequency  of  recent  exocardial 
and  endocardial  affection.  Among  the  cases  I  have  reported, 
the  former  occurred  in  the  proportion  of  39  to  107,  or  of  1  to 
every  2-7  of  the  latter;^  in  Dr.  Latham's  cases,^  of  22  to  65, 
or  of  1  to  every  2-9  ;  in  Dr.  William  Budd's,'  of  5  to  17 "3,  or 
of  1  to  every  3-4  ;  and  in  Dr.  Taylor's,^  of  8  to  25-4,  or  of  1  to 
every  3-1.  Dr.  Macleod  has  not  recorded  any  facts  which 
assist  us  in  determining  the  relative  frequenc}^  of  exocardial 
and  endocardial  disease  ;  and  Dr.  Basham  has  recorded  only 
7  instances  of  endocardial  murmur  among  his  77  cases  of 
rheumatism,  while  among  the  same  cases  he  has  noted  no  less 
than  14  instances  of  acute  pericarditis.  The  proportion  which 
endocardial  mischief  is  here  made  to  bear  to  pericarditis,  is  so 
utterly  at  variance  with  the  experience  of  all  other  observers, 
that  it  cannot  be  regarded  as  otherwise  than  exceptional,  and 
I  have  therefore  abstained  from  classing  Dr.  Basham's  cases 
with  the  others.  Possibly  Dr.  Basham,  in  the  construction  of 
his  table,  may  have  limited  his  report  in  great  measure  to  the 
number  of  instances  in  which  exocardial  mischief  was  observed. 

The  results  of  these  investigations  are   exhibited  in  the  fol- 
lowing tables  : 

Table  I. — Pericarditis. 


Cases  und?r  the  physicians 
at  St.  George's  Hospital 
Dr.  Basham's  cases    .     .     . 
Dr.  Wiu.  Budd's  cases    .     . 
Dr.  Lathams  cases    .     .     . 
Dr.  Miicleod's  cases   .     .     . 
Dr.  Taylors  cases      .     .     . 

Total 

Number  of  Cases 
of  Pericarditis. 

Number  of  Cases 

of  Acute 

Rheumatism. 

Proportion  of  Cases 
iu  which  Peri- 
carditis occurred. 

39 
14 

5 
22 
54 

8 

246 

66 

43 

136 

307 

49 

1  in  every  6-3 
1          '•        4-7 
I          "        8-6 
1          "        6-1 
1          "        5-7 
1          "        6-1 

142 

847 

1          "        5-97 

'  See  Notes  on  preceding  page. 


IN    CONNECTION    WITH    RHEUMATISM. 


Table  II. — Recent  Endocardial  Affection. 


245 


Cases  under  the  physicians 
at    St.  George's  Hospital 
Dr.  Wm.  Budd's  cases    .     . 
Dr.  Latham's  cases    .     .     . 
Dr.  Taylor's  cases      .     .     . 

Total 

Niimlier  of  Ca«es 
of  recent  Eudo- 
cardial  affection. 

Number  of  Cases 

of  Acute 

Rheumatism. 

Proporlion  of  Cases 

in  w)>ic{i  recpat 
Eudocai-dial  affec- 
tion occurred. 

107 
17-3 
65 
25-4 

246 
43 

136 
49 

1  in  every  2-29 
1  "  2-48 
1  "  2-09 
1          "        1-92 

214-7 

474 

1          "        2-25 

Table  III. 


-Relative  frequency   of  recent  Exocardial   and 
Endocardial  Affection. 


Cases  under  the  physicians 
at  St.   George's  Ho3pii;al 
Dr.  Wra.  Budd's  cases    .     . 
Dr.  Latham's  cases    .     .     . 
Dr.  Taylor's  cases      .     .     . 

Total 

Number  of  Cases 
of  Pericarditis. 

Number  of  Cases 
of  recent  Endo- 
cardial affection. 

Proportion  which 
recent  Exncaidial 
bears  t"  recent  En- 
docardial affection. 

39 

5 

22 

8 

74 

107 
17-3 
65 

25-4 

1  to  every  2-7 
1         •'         3-4 
1          "          2-9 
I          "         3-1 

214-7 

1          "         2-9 

The  great  excess  in  the  frequency  of  endocardial  aflFection 
exhibited  in  these  Tables,  arises,  I  believe,  not  from  the  greater 
frequency  of  endocarditis,  but  from  the  large  number  of  cases 
in  -which  a  murmur  is  occasioned  either  by  purely  functional 
causes,  or  by  temporary  imperfect  closure  of  the  mitial  orifice 
consequent  on  irregular  contraction  of  the  structures  connected 
with  the  valves,  or  by  the  presence  of  fibrin  deposited  on  the 
valves  without  the  concurrence  of  endocardial  inflammation. 
Judging  from  my  observation  of  the  cases  which  I  noted 
during  the  period  that  I  held  the  office  of  Medical  Registrar, 
as  also  of  those  which  have  fallen  under  my  notice  since  my 
appointment  as  one  of  the  Physicians  of  St.  George's  Hospital, 
I  believe  that  somewhat  less  than  one-third  of  all  recent  cardiac 
murmurs  met  with  among  patients  sufiering  from  acute  rheu- 
matism, will  be  found  to  result  from  pericarditis,  and  somewhat 
more  than  one-third  from  endocarditis,  while  the  remainder 
will  be  referable  to  one  of  the  three  causes  above  specified  as 


24G  STATISTICS    OF   HEART   DISEASE 

contributing  to  tlie  production  of  valvular  murmur.  This  at 
least  is  certain,  that  the  existence  of  recent  valvular  murmur 
was  not  accompanied  by  prgecordial  pain,  nor  by  any  local 
symptoms  of  inflammation,  nor  by  any  increase  in  the  general 
febrile  symptoms,  in  more  than  49  out  of  the  107  cases  before 
alluded  to,  and  that  the  murmur  ultimately  subsided  altogether 
in  many  of  the  58  cases  in  which  no  symptoms  of  inflammation 
were  observed.  The  exact  number  in  which  it  ultimately  dis- 
appeared cannot  of  course  be  ascertained,  but  it  had  entirely 
ceased  in  23  before  the  patients  left  the  hospital. 

In  strong  contrast  with  these  results,  deduced  from  the 
statistics  of  cases  treated  under  the  various  methods  usually 
adopted,  stands  the  evidence  derivable  from  the  records  of  th^ 
alkaline  mode  of  treatment,  which  I  have  employed  ever  since 
the  year  1845,  and  which  I  confidently  introduced  to  the  notice 
of  the  Profession,  in  the  first  edition  of  this  work,  published 
in  the  year  1852.  Out  of  168  patients  whom  I  have  treated 
for  acute  rheumatism  after  the  plan  then  recommended,  only 
31  have  shown  symptoms  of  cardiac  inflammation,  and  of  these 
no  less  than  26  were  afiected  before  I  saw  them,  and  4  others 
before  they  could  be  brought  under  the  influence  of  the 
remedies.  In  eight  instances,  simple  pericarditis  existed ;  in 
six  others,  pericarditis  was  complicated  with  recent  endo- 
carditis, and  in  the  other  seventeen,  endocardial  mischief  was 
present  alone.  Taking  these  figures  as  they  stand,  they  show 
pericarditis  occurring  once  in  every  12  cases,  instead  of  in 
every  5*93  cases  ;  and  endocardial  affection  once  in  every  9*8 
cases,  instead  of  in  every  2-25  cases;  while,  if  we  exclude 
those  instances  in  which  cardiac  disease  had  manifested  itself 
before  the  patient  came  under  treatment,  the  pleasing  fact 
appears,  that  pericarditis  occurred  only  once  in  every  84  cases, 
and  endocardial  aff"ection  once  in  every  56  cases.  Nor  is  this 
conclusion  inconsistent  with  the  experience  of  others.  Several 
medical  gentlemen,  who  at  my  recommendation  have  adopted 
the  alkaline  method  of  treatment,  assure  me  that  their  patients 
have  enjoyed  an  equal  immunity  from  heart  aff"ection  ;  and  Dr. 
Garrod,  who,  since  May,  1852,  has   been  following  a  similar 


IN    CONNECTION    WITH    RHEUMATISM.  247 

line  of  practice,  states  that  "in  no  case  did  affection  of  the 
heart  ensue  after  the  patient  had  been  more  than  forty-eight 
hours  under  the  influence  of  the  medicine."^  Thus  the  state- 
ments contained  in  the  first  edition  of  this  work  are  confirmed 
by  the  testimony  of  other  observers,  and  it  becomes  apparent 
that  if  the  patient  be  seen  early  and  treated  judiciously,  after 
the  method  I  was  the  first  to  recommend,  rheumatic  inflamma- 
tion of  the  heart  may  be  generally  prevented.  In  short,  the 
conviction  is  forced  upon  us  that  this  fearful  disease — fearful, 
Bot  so  much  from  the  pain  it  causes,  as  from  the  damage  it 
inflicts  on  the  central  organ  of  circulation — may  thus  be 
robbed  of  more  than  half  its  terrors. 

But  to  return  to  the  ordinary  statsitics  of  heart  disease  in 
connection  with  rheumatism. 

That  the  age  of  the  patient  has  a  powerful  influence  in 
determining  the  access  of  cardiac  mischief,  is  sufficiently 
apparent  from  the  Tables  appended  to  this  chapter,  for  it  will 
be  observed^  that  no  less  than  114  out  of  the  130  cas^s  of  recent 
heart  aff"ection  before  referred  to  occurred  in  patients  under 
the  age  of  30.  In  the  production  of  exocardial  inflammation 
alone,  its  influence  is  even  more  apparent ;  for  23  out  of  41 
instances,  or  above  one-half,  were  met  with  in  patients  who  did 
not  exceed  the  age  of  20,  and  37  out  of  the  41,  in  patients 
under  the  age  of  30,  while  4  only  out  of  the  whole  number  ex- 
ceeded that  age.  Nor  has  the  influence  of  age  been  less  strik- 
ingly  displayed  in  the  cases  observed  by  others.  Drs.  Rilliet 
and  Barthez'^  report  pericarditis  in  more  than  one-third  (4  in 
11)  of  their  rheumatic  children  patients.  Dr.  Macleod  noted 
its  occurrence  in  exactly  one-half  (4  in  8)  of  his  children 
patients;'  and  of  Dr.  Taylor's,  "  15  patients  having  rheumatic 
pericarditis,  nine,  or  two-thirds,  were  20  years  old,  or  under; 
five  between  20  and  26  years ;  and  the  remaining  one  only 
was  above  40  years  of  age."'^ 

1  "Med.-Chir.  Trans.,"  vol.  xxxviii,  p.  151. 

2  See  Table  I,  pp.  253-54. 

'  ''Traite  Clinique  et  Pratique  des  Maladies  des  Enfants,"  vol.  i,  p.  210. 

<  On  "  Rheumatism,"  pp.  15G-7. 

°  "  Medico-Chir.  Trans.,"  vol.  xxviii,  p.  528. 


248  STATISTICS    OF    HEART    DISEASE 

This  proneness  to  heart  disease,  and  more  especially  to 
inflammation  of  the  pericardium,  which  thus  appears  to  attach 
to  youth,  might  be  supposed  explicable  by  the  frequent  occur- 
rence of  acute  rheumatism  in  persons  of  tender  years.  But 
the  Tables  show^  that  this  will  not  serve  to  clear  up  the  mys- 
tery, for  although  acute  rheumatism  is  certainly  most  common 
in  early  life,  yet  the  relative  frequency  of  pericarditis  is  found 
to  vary  in  tolerably  exact  proportion  to  the  age  of  the  sufferer. 
Thus,  it  occurred  in  rather  more  than  one-third  (8  in  22,  or  1 
in  every  2*75,)  of  all  below  the  age  of  15  ;  in  less  than  one-fifth 
(15  in  82,  or  1  in  every  5-4,)  of  those  between  the  ages  of  15 
and  20 ;  and  in  less  than  one-tenth  (9  in  92,  or  1  in  every 
10-2,)  of  those  between  the  ages  of  20  and  25 ;  while,  above 
the  age  of  25,  the  proportion  of  cases  in  which  it  occurred, 
diminishes  with  even  greater  rapidity.  The  more  probable 
explanation  is  that  which  I  have  offered  in  another  chapter,^ 
viz.,  that  in  youth  the  heart  is  extremely  irritable,  and  there- 
fore specially  prone  to  suffer  from  any  disturbing  influence. 

Whether  sex  may  influence  the  production  of  heart  disease 
in  connection  with  rheumatism,  is  a  question  on  which  we  have 
hardly  enough  facts  to  warrant  our  drawing  any  positive  con- 
clusions. The  Tables  I  have  given,^  however,  show  that  some 
recent  cardiac  mischief  was  observed  in  1  out  of  every  3"1 
men  (71  in  223,)  and  in  1  out  of  every  2-2  women  (68  in  156 ;) 
that  pericarditis  occurred  once  in  every  12-4  men,  and  in  1  out 
of  every  6*7  women;  or  taking  "acute  rheumatism"  alone,  in 
1  out  of  every  7'7  men,  and  in  1  out  of  every  5*2  women ;  and 
that  recent  endocardial  affection  occurred  in  1  out  of  every  3-4 
men,  and  in  1  out  of  every  2-6  women;  or  taking  acute  rheu- 
matism alone,  in  1  out  of  every  2-4  men,  and  in  1  out  of  every 
2-1  women.  It  would  thus  appear  that  heart  disease  is  more 
common  among  women  than  among  men,  a  circumstance  which 

1  See  Tables,  pp.  253-6. 

2  Cap.  VI,  pp.  141-3. 

3  See  Tables  appended  to  this  chapter,  pp.  253-4.  The  numbers  71  and  68 
include  half  the  cases  of  uncertain  date. 


IN   CONNECTION   WITH    RHEUMATISM.  249 

accords  completely  with  the  experience  of  Dr.  Macleod,'  and 
with  the  more  recent  observations  of  my  successor,  Dr.  Bar- 
clay.^ If  the  extraordinary  proneness  to  heart  disease,  engen- 
dered by  youth,  be  attributable,  as  I  believe  it  to  be,  to  the 
greater  irritability  of  the  heart  at  that  age,  it  is  probable  that 
the  fact  of  the  heart  being  usually  more  irritable  in  women 
than  in  men,  may  be  the  reason  of  its  being  more  commonly 
affected  in  the  one  case  than  in  the  other.  Thus  this  circum- 
stance, if  verified  by  more  extended  observations,  may  serve 
as  another  link  in  the  chain  of  evidence  adduced  to  show  how 
closely  the  occurrence  of  cardiac  inflammation  is  connected 
with  the  heart's  irritability. 

The  form  which  the  articular  symptoms  assume  is  obviously 
connected  more  or  less  closely  with  the  frequency  of  cardiac 
affection,  and  affords  a  tolerable  criterion  as  to  the  probability 
of  its  occurrence.  Whether  owing  to  the  age  and  strength  of 
the  patient,  or  in  consequence  of  some  obscure  constitutional 
peculiarity,  most  certain  it  is  that  the  fibrinous  structures  are 
peculiarly  apt  to  suffer  in  youth,  and  the  synovial  membranes 
in  more  advanced  age,  and  that  the  occurrence  of  heart  affec- 
tion is  allied  most  closely  to  the  former  variety  of  articular 
inflammation.  Of  the  52  cases  of  pericarditis  reported  by  Dr. 
Macleod,  no  less  than  50  occurred  among  patients  in  whom 
the  fibrinous  symptoms  were  strongly  marked  f  Dr.  Taylor's 
instances  all  occurred  in  the  same  class  of  cases  ;*  and  so  did 
all  the  41,  save  3,  to  which  I  have  already  referred.  I  would 
not,  however,  be  misunderstood  on  this  subject.  In  acute 
rheumatism  the  fibrous  and  the  synovial  symptoms  are  usually 
more  or  less  intimately  blended,  the  fibrous  symptoms  predom- 
inating at  one  period  of  the  attack,  the  synovial  symptoms  at 

1  Dr.  Macleod  reports  '•  of  the  total  number  of  patients  laboring  under  acute 
rbeumalism,  1.37  were  males,  and  8'J  females.  Of  the  former  '18.  and  of  the 
latter  24,  had  symptoms  of  pericarditis  ;  or  of  the  men,  rather  less  than  1  in  o, 
and  of  the  women,  rather  more  than  1  in  4."     (On  "  Rheumatism,"  p.  154.) 

2  See  "  Lancet"  for  July  26th,  1851,  and  "  Medico-Chir.  Trans.,"  vol.  xxx. 
p.  18. 

*  On  "  Rheumatism,"  p.  113. 

*  "  Medico-Chir.  Trans.,"  vol.  xxviii,  p.  522. 

17 


250  STATISTICS    OF    HEART   DISEASE 

another ;  and  it  has  been  already  stated,  that  no  difference 
exists  between  those  cases  in  which  the  fibrous  symptoms  are 
most  developed  and  those  in  which  the  synovial  symptoms  are 
more  prominent,  beyond  that  which  is  impressed  upon  them  by 
peculiarities  of  age,  sex,  constitution,  and  the  like.  The  former, 
however,  are  those  which  chiefly  occur  in  youth,  and  are  marked 
by  the  greatest  amount  of  febrile  disturbance,  and  are  there- 
fore the  very  cases  which  are  especially  prone  to  the  invasion 
of  pericarditis.  Synovial  effusion  is  not  necessarily  absent, 
but  the  fibrous  symptoms  are  most  conspicuous.  I  am  not  aware 
that  the  same  relationship  has  been  traced  between  fibrous 
rheumatism  and  endocardial  inflammation  ;  nor,  indeed,  can 
such  a  relationship  be  discovered,  if  all  endocardial  murmurs 
are  to  be  taken  as  indications  of  existing  endocarditis.  But 
close  observation  has  led  me  to  believe  that  it  exists  in  an 
equally  striking  degree ;  and  that  all  efforts  to  trace  it  have 
proved  ineffectual,  simply  because  forms  of  cardiac  affection 
which  may  of  course  coexist  with  any  form  of  rheumatism,  such, 
for  instance,  as  old-standing  valvular  disease,  and  functional 
murmurs  in  no  way  referable  to  cardiac  inflammation,  have 
been  included  among  the  cases  which  have  formed  the  subject 
of  investigation.  When  these  are  excluded,  the  connection  will 
always  be  apparent  and  striking.  Of  the  107  instances  of 
recent  endocardial  affection  observed  in  connection  with  acute 
rheumatism,  58,  as  already  stated,  were  unaccompanied  by  any 
local  or  general  symptoms  of  cardiac  inflammation,  and  many 
of  these  occurred  in  patients  in  whom  synovitis  was  a  promi- 
nent feature.  But  of  the  49  which  did  present  undoubted  evi- 
dence of  cardiac  inflammation,  no  less  than  42  occurred  in 
cases  in  which  fibrous  symptoms  were  strongly  developed. 

As  to  the  exact  period  of  the  attack  at  which  heart  affection 
most  commonly  arises  I  am  not  able  to  speak  with  certainty, 
nor  indeed  can  I  conceive  that  under  any  circumstances  the 
information  obtained  at  large  public  institutions  can  give  us 
more  than  an  approximation  to  the  truth.  For,  judging  from 
my  own  observation,  nearly  half  the  instances  of  recent  cardiac 
affection  commence  before  the  patient's  admission  into  the  hos- 


IN    CONNECTION    WITH    RHEUMATISM.  251 

pital,  and  therefore  before  it  is  possible  to  obtain  any  accurate 
information  as  to  the  date  of  the  mischief ;  and  if  such  cases 
are  to  be  excluded  from  the  calculation,  the  results  cannot  be 
otherwise  than  erroneous.  The  facts  I  have  obtained,  however, 
stand  thus.  Inflammation  of  the  heart  occasionally  shows 
itself  as  the  first  and  for  some  time  the  only  local  symptom  of 
rheumatism  ;^  more  commonly  it  arises  between  the  second  and 
the  twentieth  day  of  the  attack,  and  sometimes,  when  the 
rheumatism  is  obstinate  and  lingering,  does  not  supervene 
until  the  twenty-fourth  day,  or  even  a  later  period.  In  most 
instances  it  arises  when  the  fever  is  at  its  height. 

Of  the  41  cases  of  pericarditis  already  so  often  referred  to, 
19,  at  the  date  of  their  admission  into  the  hospital,  gave  evi- 
dence of  existing  cardiac  inflammation.  On  the  average,  peri- 
carditis had  commenced  in  these  cases  before  the  seventh  day 
of  the  attack.     Of  the  remaining  22 — 

2  occurred  on  the  fifth  day  of  the  rheumatic  fever. 
5  "  sixth  " 

4  "  seventh  " 

5  "  eighth  " 
2                  "             tenth  " 

2  "  twelfth  " 
1  "  seventeenth  " 
1                 "            twenty-fourth          " 

Of  the  126  instances  of  recent  endocardial  affection  noted 
during  the  same  period,  53  existed  at  the  time  of  the  patient's 
admission  into  the  hospital ;  in  17  of  the  other  73,  in  which  a 
murmur  was  not  developed  until  after  the  patient's  admission, 
I  have  no  note  to  enable  me  to  determine  the  exact  date  of  the 
mischief;  but  of  the  remaining  56 — 

1  occurred  on  the  third  day  of  the  rheumatic  fever. 

3  "  fourth  '• 

2  "  fifth  " 
15     between  the      sixth  and  the  tenth  days. 
13             "                 tenth  and  the  fifteenth  days. 

11  "  fifteenth  and  the  twentieth  days. 

5  "  twentieth  and  the  twenty-fifth  days. 

G  after  that  date. 

1  I  have  met  with  five  instances  in  which  the  heart  was  aficcted  for  some 
time  prior  to  the  development  of  articular  symptoms ;  but  none  of  these 
occurred  among  the  cases  which  are  included  in  the  present  calculation. 


262  STATISTICS    OF    HEART    DISEASE 

Dr.  William  Budd  reports  the  occurrence  of  cardiac  affec- 
tions as  most  common  bet"\veen  the  eighth  and  the  twenty- 
seventh  day  of  the  rheumatic  attack  ;^  but  Dr.  Taylor,  who 
speaks  from  his  observation  of  15  cases,  says  heart  affection 
occurs  in  fully  one-half  of  the  cases  before  the  fourth  day  of 
the  disease.^ 

Whether  a  predisposition  to  affection  of  the  heart  may  not 
be  engendered  by  the  occurrence  of  a  previous  attack  of  peri- 
carditis or  endocarditis  is  a  question  on  which  I  have  hardly 
sufficient  data  to  enable  me  to  speak  with  confidence.  Theo- 
retically it  is  certain  that  the  occurrence  of  cardiac  inflamma- 
tion must  forever  after  render  the  heart  more  than  ordinarily 
liable  to  be  affected,  on  the  same  principle  that  a  joint  which 
has  been  strained  or  injured  is  afterward  peculiarly  suscepti- 
ble of  morbid  influences ;  and  it  is  equally  certain  that,  as  far 
as  they  go,  the  ascertained  facts  corroborate  this  view,  for 
they  show  that  the  heart  is  less  liable  to  suffer  in  primary 
invasions  of  rheumatism  than  in  cases  where  there  has  been  a 
previous  attack,  and  where,  therefore,  the  heart  may  have 
been  previously  implicated.  Of  the  246  cases  of  acute  rheu- 
matism already  referred  to,  138  were  instances  of  a  first 
attack,  84  were  cases  in  which  there  had  been  one  or  more 
previous  attacks,  and  24  were  cases  in  which,  either  from  my 
inability  to  obtain  the  requisite  information,  or  from  some 
other  cause,  I  have  made  no  note  on  the  subject.  Among 
the  cases  which  form  the  first  of  these  classes,  there  occurred 
only  59  examples  of  heart  complications,  while  there  were  no 
less  than  48  in  the  second ;  in  other  words,  some  recent  heart 
disease  occurred  in  41*8  per  cent,  of  the  first  attacks,  and  in 
55*8  of  the  subsequent  attacks.^ 

1  "  Library  of  Medicine,"  vol.  v,  p.  195. 

-  "  Medico-Chir.  Trans.,"  vol.  xxviii. 

*  The  statistics  drawn  up  by  Dr  Barclay,  my  successor  as  Medical  Regis- 
trar of  St.  George's  Hospital,  from  his  observation  of  the  cases  admitted  dur- 
ing the  two  years  ending  Dec.  31st,  1850,  show  that  cardiac  complication 
occurred  18  or  20  per  cent,  more  frequently  in  subsequent  rheumatic  attacks 
than  in  primary  ones.  For  further  details  on  this  subject,  see  ••  Med.-Chir. 
Trans.."  vol.  xxxv,  p.  18. 


IN   CONNECTION    WITH    RHEUMATISM.  253 

But  although  these  facts  exhibit  a  lesser  tendency  to  heart 
aifection  in  primary  than  in  subsequent  attacks  of  acute  rheu- 
matism, the  proportions  are  altogether  changed  when  those 
cases  only  are  examined  in  which  there  is  unequivocal  evidence 
of  true  cardiac  inflammation.  Thus,  of  the  49  cases  of  peri- 
carditis which  were  met  with  in  the  class  of  acute  rheumatism, 
25  occurred  in  primary  and  14  only  in  subsequent  attacks, 
and  in  several  of  these  14  there  was  a  tolerably  distinct  his- 
tory of  the  heart  having  been  implicated  during  the  former 
invasion  of  rheumatism.  Taking  the  figures  as  they  stand, 
however,  they  exhibit  jaericarditis  occurring  in  18*1  per  cent, 
of  the  primary  and  in  16-6  only  of  the  subsequent  attacks,  and 
afford  one  among  many  presumptive  proofs  that  a  large  pro- 
portion of  the  endocardial  murmurs  which  arise  during  the 
course  of  acute  rheumatism,  are  not  attributable  to  true  in- 
flammation. 


Table  I. 

Abstract  of  Cases  of  Acute  and  Subacute  Rheumatism^  admitted  into  St.  George's 
Hospital,  between  the  1st  of  January,  1845,  and  the  1st  of  May,  1848,  showing 
the  number  which  were  complicated  by  disease  of  the  Heart ;  the  Age  and  Sex  of 
the  Patients  in  whom  it  occurred,  the  form  which  it  assumed,  and  the  proportion 
in  which  each  form  occurred  among  the  tivo  Sexes. 

Total  number  of  Cases,  379.     Of  which,  223  occurred  ia  men,  and  15(3  in 

women. 
Heart  affected  in  187  instances.     Healthy  in  IGO  instances.     Not  noted  in  32. 
Of  the  187  instances  of  Heart  affection,  130  were  cases  in  which  the  disease 

was  of  recent  origin. 
"  "  39  were  cases  in  which  the  disease 

was  of  old  standing. 
"  "  18  were  cases  in  which  the  disease 

was  of  uncertain  date. 
Of  the  130  cases  of  recent  Heart  disease,   13  were    instances  of  Pericarditis 

alone. 
"  "  28  Avere  instances  of  Endo-pericar- 

ditis. 
"  "  89  were   instances   of  Endocardial 

affection  alone. 
The  18  cases  of  uncertain  date  were  all  instances  of  Endocardial  disease. 
Of  the  13  cases  of  Pericarditis,  G  occurred  in  men,  and  7  in  women. 


254 


STATISTICS    OF   HEART   DISEASE 


Of  the  28  cases  of  Endo-'pericarditis,  12  occurred  iu  men,  and  16  in  women. 
"     89       "         recent  Endocardial  affection,  48  occurred  in  men,  and  41  in 

women. 
"     39       "         old-standing  disease,  23  occurred  in  men,  and  16  in  women. 
"     18       "         uncertain  date,  10  occurred  in  men,  and  8  in  women. 
Pericarditis  then  occurred  once  in  every  12-4  men,  and  once   in  every  6-7 

women. 
Recent  Endocardial  affection  once  in  every  3-4  men,  and  once  in  every  2-G 

women. 
Old-standing  Heart  disease  once  in  every  7-9  men,  and  once  in  every  7-8 
women. 


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49 

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11 

26 

4 

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20—25 

92 

49 

3 

6 

26 

9 

5 

25—30 

79 

41 

1 

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22 

9 

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30—35 

40 

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35—40 

28 

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Table  II. 


Abstract  of  Cases  of  Acute  RheumatKtn,  admitted  into  St.  George's  Hospital^  from 
January  \st,  1845,  to  May  \st,  1848,  shotving  the  number  which  were  compli- 
cated by  Heart  Disease ;  the  Age  and  Sex  of  the  Patients  in  whom  it  occurred, 
the  form  which  it  assumed,  and  the  proportion  in  which  each  form  occurred 
among  the  two  Sexes. 

Total  number  of  Cases,  246.     Of  which   131   occurred  in  men,  and  115  in 

women. 
Heart  affected  in   145  instances.     Healthy  in  93  instances.     Not  noted,  and 

therefore  probably  healthy  in  8. 
Of  the  145  instances  of  Heart  affection,  114  were  cases  in  which  the  disease 

was  of  recent  origin. 
"  "  "  21  were  cases  in  which  the  disease 

was  of  old  standing. 
"  "  "  10  were  cases  in  which  the  date  of 

the  disease  was  uncertain. 
Of  the  114  cases  of  recent  Heart  disease,  12  were  cases  of  Pericarditis  alone. 


IN    CONNECTION   WITH    RHEUMATISM. 


255 


Of  the  114  cases  of  recent  Heart  disease,  27  were  case^of  Endo-pericarditis. 

"  "  "  75  were  cases  of  Endocardial  affection 

alone. 
The  10  cases  of  uncertain  date  were  all  instances  of  Endocardial  disease. 
Of  the  12  cases  of  Pericarditis,  5  occurred  in  men,  and  7  in  women. 

"      27        "        Endo-pericarditis,  12  occurred  in  men,  and  15  in  women. 
"      75        "        Recent  Endocardial  aftection,  39  occurred  in  men,  and  36 

in  women. 
"      21        "        Old-standing  disease,  11  occurred  in  men,  and  10  in  women. 
"       10        "         uncertain  date,  G  occurred  in  men,  and  4  in  women. 
Pericarditis  then  occurred  once  in  every  7-7  men,  and  once  in  every  5-2  women. 
Recent  Endocardial  aflection  once  in  every  2-4  men,  and  once  in  every  2-1 

women. 
Old-standing  Heart  affection  once  in  every  9-3  men,  and  once  in  every  9-5 
women. 


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246 

145 

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Table  III. 

Abstract  of  Cases  of  Subacute  Rheumatism,  admitted  into  St.  Georffe's  Hospital, 
between  the  1st  of  January,  1845,  and  the  \st  of  May,  1848,  shoiving  the  number 
complicated  by  Heart  disease ;  the  Age.  and  Sex  of  the  Patients  in  whom  it 
occurred,  the  form  which  it  assumed,  and  the  proportion  in  ivhich  each  form 
occurred  among  the  two  Sexes. 

Total  number  of  Cases,  133.     Of  which  92  occurred  in  men,  and  41  in  women. 
Heart  affected  in  42  instances.     Healthy  in  67  instances.     Not  noted  in  24. 
Of  the  42  instances  of  Heart  affection,  16  were  cases  in  which  the  disease  was 

of  recent  origin. 
"  "  "  18  were  cases  in  which  the  disease  was 

of  old  standing. 
"  "  "  8  were  cases  in  which  the  date  of  the 

disease  was  uncertain. 


256 


STATISTICS    OF    HEART   DISEASE. 


Of  the  IG  cases  of  recerrt  Heart  disease,  1  was  a  case  of  Pericarditis  alone. 
"  "  "  1  was  a  case  of  Endo-pericarditis. 

"  "  "  14  were  cases  of  Endocardial  affection 

alone. 
The  8  cases  of  uncertain  date  were  all  instances  of  Endocardial  disease. 
The  1  case  of  Pericarditis  occurred  in  a  man. 
The  1  case  of  Endo-pericarditis  occurred  in  a  woman. 

Of  the  14  cases  of  recent  Endocardial  affection,  9  occurred  in  men,  and  5  in 
women. 
"       18         "         old-standing  disease,  12  occurred  in  men,  and  ()  in  women. 
"         8         "         uncertain  date,  4  occurred  in  men,  and  4  in  women. 
Pericarditis  then  occurred  once  in  every  92  men,  and  once  in  every  41  women; 
or  in  little  more  than  1  per  cent,  among  the  men,  and  i  per  cent,  among 
the  women. 
Recent  Endocardial  affection  occurred  once  in  every  8-3  men,  and  once  in 

every  5-1  women. 
Old-standing  Heart  disease  occurred  once  in  every  6-5  men,  and  once  in  every 
5-1  women. 


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CHAPTER  X. 

ON  AFFECTIONS  OF  THE  BRAIN,  INFLAMMATION  OF  THE 
LUNGS  AND  PLEUR.E,  AND  DISORGANIZATION  OF  THE 
JOINTS. 

Although  inflammation  of  the  membranes  of  the  heart  is  by 
far  the  most  common  complication  of  acute  rheumatism,  yet  do 
we  sometimes  meet  with  symptoms  indicative  of  derangement 
in  other  organs.  Among  these,  the  most  formidable  are  sug- 
gestive of  disorder  of  the  cerebral  structures.  A  patient,  for 
instance,  who  for  a  week  or  ten  days  has  been  suffering  from 
acute  rheumatism,  and  has  presented  no  untoward  symptom, 
after  passing  one  or  two  restless  nights  becomes  strange  and 
flighty  in  his  manner,  complains,  perhaps,  of  headache,  and  is 
shortly  seized  with  furious  delirium,  during  which  he  appears 
to  be  insensible  to  pain,  and  moves  his  limbs  in  utter  disregard 
of  his  inflamed  and  exquisitely  painful  joints.  And  then,  if  he 
does  not  shortly  improve,  he  either  dies  of  exhaustion  or  falls 
into  a  state  of  profound  coma,  and  expires  in  the  course  of  a 
few  hours. ^ 

Symptoms  such  as  these  were  formerly  referred  to  inflamma- 
tion of  the  brain  or  its  meninges,  and  the  unfortunate  sufferer 
was  bled  from  the  arm,  or  leeched  on  the  temples,  and  subjected 
to  such  other  antiphlogistic  treatment  as  appeared  called  for 
by  the  urgency  of  the  supposed  cerebral  symptoms.^  But 
pathological  research  has  at  length  discovered  that  cerebral 
disturbance  is  not  always  symptomatic  of  cerebral  inflammation, 
and  that  a  patient  suffering  from  acute  rheumatism  may  pass 
into  a  state  of  violent  delirium,  and  die  comatose  or  convulsed, 

1  Some  of  these  cases  are  characterized  from  the  first  by  a  strange  wayward- 
ness and  taciturnity. 

2  For  an  illustration  of  this  fact,  consult  the  record  of  a  case  reported  by 
Mr.  Stanley,  in  the  seventh  volume  of  the  "  Medico-Chir.  Trans." 


258  AFFECTIONS    OF    THE    BRAIN 

although  on  dissection  neither  the  brain  nor  its  membranes 
present  the  slightest  trace  of  inflammatory  action.  Nay,  more, 
it  has  been  proved  beyond  dispute,  that  although  in  some  rare 
instances  the  symptoms  alluded  to  do  indicate  inflammation  of 
the  brain  or  its  meninges,  yet  that  such  is  very  rarely  the  case  ; 
that,  more  generally,  they  are  coincident  with  inflammatory 
action  about  the  heart,  and  are  unconnected  with  any  cerebral 
lesion  ;  not  unfrequently  accompany  pleuritis  or  pneumonia ; 
and  occasionally  present  themselves  to  an  alarming  extent, 
when  neither  the  brain,  nor  the  heart,  nor  the  lungs  are 
afiected. 

The  question,  therefore,  naturally  suggests  itself, — to  what 
are  these  cerebral  symptoms  attributable  ?  Are  they  to  be 
regarded  as  tokens  of  threatening  mischief  within  the  cranium  ? 
or  as  evidences  of  the  lighting  up  of  some  distant  internal  local 
inflammation  ?  or  as  expressions  of  alarm  experienced  by  the 
system  generally,  and  by  the  sensorium,  the  source  of  the 
system's  consciousness,  at  the  interference  with  its  nutrition 
resulting  from  the  poisoned  condition  of  the  blood  ? 

To  me  I  confess  the  latter  appears  the  only  satisfactory 
explanation. 

At  one  time  all  cerebral  symptoms  which  occurred  in  the 
course  of  acute  rheumatism  were  referred  to  inflammation  of  the 
brain  or  its  membranes,  resulting,  as  was  supposed,  from 
metastasis  of  the  morbid  action  to  the  cerebral  structures,  in 
consequence  of  the  subsidence  of  articular  inflammation.  But 
their  independence  of  metastatic  action  is  attested,  by  their  not 
unfrequent  occurrence  without  the  subsidence  of  articular 
inflammation  ;  and  their  independence  of  mischief  developed 
within  the  cranium  is  abundantly  proved  by  dissection  after 
death,  which,  even  when  the  case  has  terminated  fatally,  fails 
utterly,  in  most  cases,  in  affording  the  slightest  evidence  of 
cerebral  mischief.* 

« 

1  In  proof  of  this,  I  would  refer  to  the  case  recorded  at  pp.  275-6  of  this 
Treatise,  as  also  to  the  valuable  cases  reported  by  Dr.  Richard  Bright,  in  his 
account  of  spasmodic  diseases  accompanying  affections  of  the  pericardium  ;  by 
Dr.  George  Burrows,  in  his  worii  on  "  Disorders  of  the  Cerebral  Circulation  ;" 


AS    CONSEQUENCES    OF  ACUTE   RHEUMATISM.  iJ59 

The  second  sugo-estiGn  is  more  in  accordance  with  sound 
pathology,  but  nevertheless  is  not  quite  satisfactory.  Soon  after 
the  discovery  that  cerebral  disturbance  may  arise  in  the  course 
of  acute  rheumatism,  without  the  concurrence  of  cerebral 
inflammation,  delirium  was  so  often  found  associated  with 
active  cardiac  disease,  that  many  persons  were  led  to  regard 
disorder  of  the  sensorial  functions  as  invariably  connected  with 
mischief  occurring  in  the  central  organ  of  the  circulation.  The 
old-fashioned  doctrine  of  metastasis  to  the  brain  exploded  under 
the  influence  of  pathological  research,  and  the  heart  was  in 
every  case  pronounced  to  be  the  "fons  et  origo  malorum."  By 
some,  its  anatomical  relations  with  the  cerebrum  were  pointed 
to,  in  explanation  of  the  symptoms  observed,  and  the  delirium 
was  attributed  to  irritation  conveyed  to  the  brain  by  the  phrenic^ 
and  pneumogastric^  nerves,  as  a  consequence  of  inflammation 
of  the  pericardium  or  endocardium.  By  others,  however,  sym- 
pathetic irritation  was  considered  inadequate  to  explain  the 
symptoms,  which  were  therefore  attributed  to  disturbance  of 
the  cerebral  circulation,  occasioned  by  the  embarrassment  of 
the  heart's  action,  which  results  from  the  access  of  cardiac 
inflammation.^  But  neither  of  these  interpretations  appears  to 
me  correct,  inasmuch  as  delirium,  convulsions,  and  coma  are 
always  rare  and  exceptional  phenomena,  even  when  carditis 
terminates  fatally ;  not  unfrequently  arise  in  cases  distinguished 
by  less  than  the  average  severity  of  their  cardiac  symptoms, 
and  in  which,  therefore,  presumption  favors  the  belief,  that 
there  is  no  unusual  irritation  of  the  cardiac  nerves  ;  and  occur 
sometimes  when  dissection  after  death  proves  the  heart  and  its 
membranes  to  be  quite  free  from  disease,  and  Avhen,  therefore, 

by  Dr.  Latham,  in  his  work  on  "Clinical  Medicine;"  by  Dr.  Todd,  in  his 
Lumleian  Lectures  ;  and  by  Dr.  Watson,  in  his  "  Practice  of  Physic."  Andral, 
Bouillaud,  Davis,  Rostan,  Stanley,  and  others,  have  reported  similar  symptoms 
connected  with  pericarditis,  when  occurring  without  any  accompanying  rheu- 
matism. 

1  Dr.  R.  Bright  and  M.  Bouillaud. 

2  Dr.  Hope,  op.  cit. 

3  Dr.  Watson's  "  Practice  of  Physic,"  ed.  1,  vol.  ii,  p.  276;  and  Dr.  Burrows 
on  "Disorders  of  the  Cerebral  Circulation,"  p.  212. 


260  AFFECTIONS    OF   THE    BRAIN 

the  non-existence  of  such  a  cause  of  irritation  is  placed  beyond 
all  doubt.^ 

The  same  observations  apply  -with  equal  if  not  greater  force, 
to  those  instances  in  which  cerebral  symptoms  are  coincident 
■with  inflammation  of  the  respiratory  organs.  That  consider- 
able disturbance  of  the  sensorial  functions  is  sometimes  associ- 
ated with  pleurisy  and  pneumonia  when  occurring  in  the  course 
of  acute  rheumatism,  is  a  fact  familiar  to  all  practical  men,  nor 
can  it  admit  of  question,  that  such  a  complication  must  inter- 
fere materially  with  the  maintenance  of  a  due  circulation 
through  the  brain.  But  equally  certain  is  it,  that  extensive 
mischief  may  take  place  in  the  lungs,  or  within  the  cavities  of 
the  pleurre,  unattended  by  any  symptoms,  however  slight,  of 
cerebral  disturbance ;  and,  on  the  other  hand,  that  delirium  of 
a  most  violent  character  may  be,  and  frequently  is  met  with, 
unaccompanied  by  any  evidence,  either  general  or  physical,  of 
pulmonary  inflammation.  So,  even  admitting  that  carditis  and 
pleuro-pneumonia  do  exercise  some  influence  in  producing 
cerebral  disturbance,  they  can  be  regarded  only  as  occasional 
and  accessory  causes. 

It  is  far  different,  however,  in  regard  to  the  third  suggested 
cause  of  rheumatic  delirium.  The  blood,  in  every  case  of  rheu- 
matism, is  poisoned  by  the  presence  of  morbific  matter,  and  the 
nutrition  of  the  brain  is  interfered  with  in  consequence  ;  and 
although  delirium,  convulsions,  and  coma  may  result  in  turn 
from  cerebro-spinal  inflammation,  yet  an  altered  condition  of 
the  circulating  fluid  is  equally,  if  not  more  energetic  in  their 
production.^     Every  one,  for  instance,    knows  how  certainly 

1  In  a  review  of  the  first  edition  of  this  work,  it  was  suggested  that  the 
detachment  of  fibrinous  vegetations  from  the  valves  on  the  left  side  of  the 
heart,  and  their  impaction  in  the  vessels  supplying  the  brain,  may  be  the  cause 
of  cerebral  disturbance  in  these  cases.  This  supposition,  however,  is  simply 
gratuitous,  and  without  foundation.  In  the  valuable  records  of  fibrinous  plug- 
ging of  the  cerebral  vessels,  published  by  Dr.  Kirkes,  in  vol.  xxxv  of  the 
"  Medico-Chirurgical   Transactions,"  hemiplegia,   and  not  delirium,  resulted 

rom  the  cause  alluded  to  ;  and  extensive  softening  of  the  cerebral  structure  was 
the  characteristic  pathological  phenomenon — results  totally  unlike  those  which 
are  met  with  in  connection  with  rheumatic  delirium. 

2  For  full  and  copious  illustrations  of  this  important  fact,  see  Dr.  Todd's 
Lumleian  Lectures  for  1850. 


AS    CONSEQUENCES    OF   ACUTE    RHEUMATISM.  261 

excitement  or  profound  coma  is  caused  by  the  ingestion  of 
inordinate  quantities  of  spirituous  liquors,  and  by  the  action  of 
belladonna  and  other  poisonous  agents  ;  how  frequently  delirium 
results  from  the  deleterious  influence  of  urea,  and  how  often  it 
accompanies  typhus  fever,  erysipelas,  and  almost  every  exanthe- 
matous  disorder.  Yet,  in  all  these  cases,  dissection  after  death 
has  shown  that  such  symptoms  afford  not  the  slightest  ground 
for  the  presumption  of  cerebral  congestion  or  cerebral  inflam- 
mation. The  brain  has  been  found  paler  and  drier  than  usual, 
or  of  a  darker  color,  and  marked  by  an  increased  number  of 
bloody  puncta,  and  sometimes  a  small  quantity  of  serum  has 
been  discovered  under  the  pia  mater  or  in  the  ventricles,  as  the 
result  of  a  retarded  cerebral  circulation.  Rarely,  however, 
has  there  been  any  trace  of  inflammatory  action,  or  of  any  other 
organic  lesion.  In  fact,  experience  has  shown,  that  whenever 
the  blood  is  poisoned,  or  altered  in  character,  as  it  is  in  all  the 
cases  referred  to,  there  may  occur,  without  any  local  inflamma- 
tion, every  shade  and  variety  of  cerebral  disturbance,  from 
slight  wandering  or  flightiness  to  violent  maniacal  delirium, 
accompanied  or  unaccompanied  by  convulsions,  or  tetanic 
spasms,  and  terminating  in  recovery,  or  in  death  by  coma. 

A  distempered  condition  of  the  blood,  then,  I  conceive  to  be 
the  true  proximate  cause  of  the  sensorial  disturbance  occasion- 
ally observed  in  the  course  of  acute  rheumatism.^  For  while 
we  find  acute  rheumatism  attended  by  every  species  of  delirium, 
and  every  variety  of  spasmodic  action,  we  find  almost  invari- 
ably, as  in  the  cases  just  alluded  to,  a  total  absence  of  morbid 
appearances  within  the  cranium  or  the  spinal  cord,  capable  of 
accounting  for  the  cerebral  or  cerebro-spinal  disturbance.  And 
although  this  disturbance  is  sometimes  associated  with  inflam- 
mation in  other  organs,  yet  instances  are  not  wanting  in  which 
delirium,   by   taking    place  without   the   concurrence   of   any 

^  Dr.  Todd  has  urged  this  view  most  closely  and  forcibly  in  bis  admirable 
Lectures  on  Delirium  and  Coma,  delivered  before  the  Royal  College  of  Physi- 
cians, but  he  does  not  appear  to  have  dwelt  sufficiently  on  the  causes  which 
give  effect  to  the  operation  of  the  poison  in  certain  cases,  and  which  by  iheir 
absence  prevent  cerebral  disturbance  in  others. 


262  AFFECTIONS   OF   THE   BRAIN 

internal  injflammation,  asserts  its  independence  of  all  local 
action,  and  ranks  itself  among  the  symptoms  known  to  be 
dependent  on  a  vitiated  condition  of  the  circulating  fluid ;  a 
position  which  is  strongly  supported  by  the  fact  that,  in  gout, 
an  analogous  disorder,  in  which  the  blood  has  been  shown  to 
be  poisoned,^  we  meet  with  a  similar  affection  of  the  nervous 
centres,  unaccompanied  by  any  evidence  of  cerebro-spinal 
inflammation. 

But  admitting  the  altered  condition  of  the  blood  to  be  the 
primary  cause  of  the  brain's  disturbance,  yet  as  its  character 
is  always  altered  in  rheumatism,  and  head  symptoms  seldom 
occur,  there  must  be  some  further  influences  at  work  which 
determine  the  occurrence  of  delirium  in  certain  cases  and  its 
total  absence  in  others.  By  looking  carefully  to  the  circum- 
stances under  which  cerebral  symptoms  are  most  apt  to  arise 
in  diff"erent  disorders,  we  may  glean  important  information  on 
the  subject.  It  is  well  known  that  persons  of  a  nervous  ex- 
citable disposition  are  more  apt  to  experience  ill  effects  from 
any  interference  with  their  functions,  than  are  others  of  a  more 
vigorous  and  less  irritable  temperament.  Moreover,  it  has 
been  ascertained  that  nervous  susceptibility  is  most  fully  dis- 
played when  the  constitution  has  been  damaged  by  habits  of 
intemperance  or  by  long-continued  ill  health.  Not  only  are 
persons  more  prone  under  such  circumstances  to  suff'er  severely 
from  local  injuries,  but  they  are  apt  to  exhibit  symptoms  of 
irritation  from  causes  which,  in  persons  of  a  healthy  constitu- 
tion and  less  excitable  habit,  would  hardly  give  rise  to  any 
disturbance.  Thus  it  is  that  in  habitual  drunkards,  whose 
constitutions  are  shattered,  and  whose  nervous  systems  have 
long  been  unduly  exalted  or  depressed,  comparatively  small 
potations  on  the  one  hand,  or  on  the  other  a  brief  abstinence 
from  accustomed  stimulus,  or  any  temporary  depressing  cause, 
will  seldom  fail  to  induce  an  attack  of  delirium  tremens.  Hence 
also  the  frequency  of  traumatic  delirium,  and  of  the  delirium 
which  so  constantly  accompanies  erysipelas  in  persons  whose 
constitutions  have  been  severely  taxed.  The  excess  or  the 
1   Vide  '•  Medico-Chir.  Transactions,"  vol.  xxxi,  p.  83. 


AS    COXSEQUENCES    OF  ACUTE    RHEUMATISM.  263 

deficiency  of  the  accustomed  stimulus  in  the  case  of  the  drunk- 
ard ;  the  sjhock,  and  the  loss  of  hlood  in  the  case  of  the  wounded 
man;  and  the  poison  of  the  disease  in  the  last  instance,  proves 
sufficient  to  disturb  the  relationship  subsisting  between  the 
blood  and  the  nervous  centers.  With  a  brain  participating  in 
the  general  mal-nutrition  of  the  body, — a  heart  weak,  ill 
nourished,  ill  supplied  with  nervous  stimulus,  and  hardly 
capable  of  maintaining  a  due  circulation, — and  a  blood  long 
vitiated  or  impoverished,  it  is  not  difficult  to  conceive  that  a 
slight  additional  cause  of  irritation  or  depression  may  prove 
sufficient  to  disturb  the  brain's  equilibrium,  and  that  an  attack 
of  delirium  may  supervene,  whenever,  by  the  presence  of  some 
fresh  morbific  matter,  by  an  increase  of  the  watery  part,  or  a 
diminution  in  the  colored  corpuscles  of  the  blood,^  or,  indeed, 
by  any  material  alteration  in  the  character  of  the  circulating 
fluid,  the  nutrition  of  the  nervous  centers  is  still  further  in- 
terfered with.  Nor  is  it  to  be  wondered  at  that,  from  the  same 
cause,  an  attack  of  carditis,  or  pleuro-pneumonia,  should  in 
many  cases  determine  the  access  of  cerebral  symptoms.  The 
shock  resulting  from  the  occurrence  of  inflammation  in  such 
vital  organs  as  the  heart  or  lungs,  must  surely  so  far  influence 
the  circulation  as  to  cause  the  blood  to  be  sent  to  the  brain 
less  forcibly  and  less  regularly  than  before:  indeed,  we  have 
proof  of  such  an  influence  in  the  weak,  irregular,  and  inter- 
mittent pulse,  by  which  the  invasion  of  carditis  is  often  accom- 
panied ;  and  this,  in  a  person  already  predisposed  by  the  vitiated 
condition  of  the  blood,  would  probably  disturb  the  brain's  nutri- 
tion sufficiently  to  give  rise  to  symptoms  of  undue  excitement 
or  undue  oppression." 

Thus,  then,  it  would  appear  that,  in  all  cases  in  which  cere- 
bral disturbance  presents  itself  during  the  course  of  acute  rheu- 

1  The  natural  result  of  hemorrhage  or  venesection. 

'■*  "With  the  heart  patched  inside  and  out  with  lymph,  ulcerated  it  may  be 
in  its  very  substance  and  valvular  structure,  while  fevered  acid  blood  is  at  the 
same  time  in  circulation  through  the  system,  there  can  be  no  reason  to  marvel 
at  the  occurrence  of  'head  symptoms'  in  rheumatic  fever,  even  though  the 
brain  and  its  investing  membranes  be  not  inflamed."  (Dr.  Wilson,  "  On  the 
True  Character  of  Acute  Rheumatism."     "Lancet"  for  1844,  vol.  ii,  p.  218.) 


264:  AFFECTIONS    OF   THE    BRAIN 

matism,  the  altered  condition  of  the  hlood  is  its  primary  or 
proximate  cause ;  that  neither  delirium  nor  coma  is  necessarily 
accompanied  hy  any  internal  inflammation,  whether  of  the 
brain,  the  heart,  or  the  lungs:  nevertheless,  internal  inflam- 
mation, more  especially  of  the  heart  and  lungs,  is  very  liable 
to  arise  as  a  consequence  of  the  irritation  of  the  vitiated  blood  ; 
and  "when  so  arising,  is  apt  to  be  accompanied  by  sensorial 
derangement,  for  the  reason  that,  under  the  circumstances  of 
the  case,  it  makes  up  the  sum  or  amount  of  derangement  which 
is  requisite  to  disturb  the  brain's  equilibrium.  Indeed,  so 
rarely  is  such  disturbance  effected  in  acute  rheumatism  without 
its  influence,  that  for  all  practical  purposes  delirium  may  be 
considered  as  indicative  of  some  commencing  internal  compli- 
cation, and  very  generally  of  inflammation  of  the  heart. 

The  same  holds  good  in  regard  to  those  cases  which  are 
attended,  not  only  by  disturbance  of  the  intellectual  faculties, 
but  by  symptoms  indicative  of  spinal  irritation.  Just  as  deli- 
rium may  result  from  the  direct  action  of  the  rheumatic  poison 
on  the  brain,  so  convulsions,  and  other  spasmodic  affections, 
which  are  sometimes  met  with  in  acute  rheumatism,  may  take 
their  origin  in  spinal  irritation  caused  by  the  action  of  the  same 
morbific  agent.  In  the  first  named  cases,  dissection  after  death 
very  generally  fails  in  revealing  any  trace  of  mischief  within 
the  cranium;  and,  in  the  last,  the  spinal  cord  and  its  mem- 
branes are  found  equally  free  from  organic  lesion.  Both  classes 
of  cases,  however,  are  usually  distinguished  by  extensive  in- 
flammation of  the  pericardium  or  pleurae;  and  in  the  one,  as  in 
the  other,  this  local  inflammation  appears  to  be  connected  with, 
if  indeed  it  be  not  the  exciting  cause  of  the  disturbance  observed 
in  the  cerebro-spinal  functions.  In  the  former  it  obviously 
interferes  with  the  due  maintenance  of  the  cerebral  circulation, 
and  is  thus  probably  conducive  to  the  setting  up  of  delirium: 
in  the  latter  it  doubtless  produces  a  similar  derangement  in  the 
spinal  system,  and  so  gives  rise  to  convulsive  actions.  Probably, 
however,  the  symptoms  in  the  latter,  if  not  also  in  the  former 
cases,  are  more  or  less  connected  with  the  irritation  of  those 
branches  of  the  phrenic  and  pneumogastric  nerves  which  are 


AS    CONSEQUENCES    OF    ACUTE    RHEUMATISM.  265 

distributed  over  the  inflamed  part.s;  for  it  lias  been  observed 
that,  in  the  cases  most  remarkable  for  choreic  or  tetanic  con- 
vulsions, and  other  symptoms  of  spinal  irritation,  the  inflam- 
mation has  not  been  confined  to  the  internal  surface  of  the 
pericardium,  but  has  extended  to  its  external  surface  and  to 
the  diaphragmatic  pleura,  where  branches  of  the  phrenic  and 
pneumogastric  nerves  are  distributed  most  abundantly.^ 

The  description  I  have  given  of  the  circumstances  under 
which  cerebro- spinal  symptoms  are  most  apt  to  make  their 
appearance,  sufficiently  indicates  the  class  of  cases  in  which 
we  may  reasonably  expect  their  occurrence.  It  is  not  neces- 
sarily in  those  persons  whose  articular  inflammations  are  most 
numerous  and  severe,  but  in  those  who  are  pale,  weakly,  and 
unhealthy;  who  have  been  much  reduced  by  blood-letting, 
or  by  excessive  and  long-continued  perspiration ;  who  are 
attacked  after  overlong  lactation,  or  during  recovery  from 
serious  illness ;  or  who  again,  as  Dr.  Watson  has  remarked,^ 
experience  a  relapse  after  a  long  and  tedious  attack  of  rheu- 
matism. It  is  with  rheumatism,  just  as  with  gout ;  the  pleth- 
oric healthy  subject,  though  undergoing  martyrdom  from 
inflammation  of  his  joints,  escapes  without  the  slightest  disturb- 
ance of  his  sensorial  functions,  while  the  thin,  the  sallow,  and 
unhealthy,  who  have  long  suff"ered  from  constitutional  derange- 
ment, whose  kidneys  and  liver  are  defective  in  action,  whose 
blood  is  altogether  vitiated,  and  whose  nervous  centers  cannot 

to  '      » 

fail  to  sympathize  largely  in  the  general  disturbance,  though 
presenting  far  less  active  local  symptoms  of  disease,  are  aff'ected 
with  delirium,  and  die  comatose  or  convulsed. 

Thus,  then,  as  head  symptoms  are  invariably  connected 
with  great  susceptibility  of  the  nervous  centers,  are  usually 
accompanied  by  active  inflammation  of  some  internal  organ, 
and  occur  almost  always  in  persons  of  a  weak  excitable  habit, 

^  For  cases  in  illustration  of  these  facts,  see  Dr.  R  Bright's  essay  "On 
Spasmodic  Diseases  accompanying  Affection  of  the  Pericardium,"  "Medico- 
Chir.  Trans.,"  vol.  xxii ;  BouilUiud's  "  Traite  des  Maladies  du  Coeur  ;"  Dr.  Bur- 
rows, "On  Disorders  of  the  Cerebral  Circulation,"  pp.  210-212;  and  Dr.  Hcpe, 
"  On  Diseases  of  the  Heart." 

2  "  Practice  of  Physic,"  ed.  1,  vol.  ii,  p.  283. 
18 


266  AFFECTIONS    OF    THE    BRAIN 

they  are  always  indicative  of  extreme  danger,  even  when  unat- 
tended by  cerebral  inflammation.  That  recovery  does  take 
place  occasionally,  I  am  satisfied  both  by  personal  experience, 
and  by  the  testimony  of  others  who  have  watched  and  noted 
cases  in  point,  but,  when  the  delirium  is  violent,  and  of  long 
continuance,  the  result  cannot  be  otherwise  than  doubtful. 
Whether  recovery  does  ever  occur  when  the  delirium  is  de- 
pendent upon  cerebral  inflammation,  it  is  impossible  from  ex- 
perience to  decide,  inasmuch  as  convalescence  itself  forms  a  bar 
against  our  only  source  of  positive  information.  But  if,  in  any 
case  accompanied  by  symptoms  of  active  cerebral  disturbance, 
no  cardiac  or  pulmonary  disease  should  be  detected,  it  would  be 
right,  cseteris  paribus^  to  speak  more  decidedly  as  to  an  unfa- 
vorable issue,  than  if  the  stethoscope  had  revealed  mischief 
within  tlie  chest. 

The  following  instructive  case,  which  fell  under  my  observ- 
ation in  St.  George's  Hospital,  affords  a  good  example  of  the 
class  of  cases  in  which,  and  of  the  circumstances  under  which, 
rheumatic  delirium  is  most  liable  to  occur,  as  also  of  the  train 
of  symptoms  by  which  it  is  accompanied. 

Harriet  Keating,  a  poor,  thin,  over-worked  girl,  set.  19,^ 
was  admitted  into  the  Holland  Ward  on  the  9th  of  October, 
1850,  under  the  care  of  my  colleague.  Dr.  Wilson.  She  had 
been  seized  with  acute  rheumatism  in  the  year  1848,  and  had 
undergone  four  similar  attacks  ^ince  that  date.  Her  present 
attack,  which  had  been  preceded  for  three  Aveeks  by  languor, 
chilliness,  wandering  pains,  and  general  uneasiness,  commenced 
on  the  6th  instant  with  redness  and  swelling  of  the  knees.  On 
the  8th,  the  day  prior  to  her  admission,  she  had  been  bled  to 
the  extent  of  a  pint  with  slight  temporary  relief,  but  when  she 
was  admitted,  the  knees  and  ankles  were  red,  swollen,  and 
extremely  painful,  her  countenance  was  anxious,  and  she  had 
a^weak  pulse  of  120.  On  the  following  day  she  was  decidedly 
worse ;  her  countenance  was  more  anximis,  she  was  com- 
plaining of  excessive  pain  in  the  limbs,  and  had  experi- 
enced several  fits  of  shivering.  On  the  11th,  after  a  restless 
and  sleepless  night,  during  which  the  inflammation  shifted  to 
1  .She  was  a  servant  of  all  work. 


AS    CONSEQUENCES    OF    ACUTE    RHEUMATISM.  267 

the  right  wrist  and  elbow,  she  presented  symptoms  even  more 
alarming  than  on  the  previous  day.  Her  face  was  flushed, 
and,  though  no  distinct  murmur  could  be  heard  accompanying 
the  heart's  sounds,  the  pulse  had  risen  to  130,  and  Avas  sharp 
and  somewhat  irregular.  The  morning  of  the  12th  found  the 
inflammation  again  shifted  to  the  inferior  extremities,  her  face 
more  flushed,  the  pulse  quicker,  sharper,  and  more  irregular, 
and  the  heart's  sounds  accompanied,  or  rather  masked  by  a 
loud  to-and-fro  sound  of  friction.  The  treatment  up  to  this 
time  had  consisted  of  lemon-juice,  with  occasional  doses  of 
opium  or  morphia,  but  twelve  ounces  of  blood  were  now  taken 
from  the  arm,  and  she  was  put  upon  calomel  and  opium,  while 
leeches  and  mustard  poultices  were  applied  to  the  chest.  By 
the  20th  she  was  greatly  relieved ;  she  had  passed  a  tolerably 
good  night ;  the  dullness  on  percussion  in  the  prsecordial  re- 
gion had  greatly  decreased,  the  heart's  sounds  were  clearer 
and  louder,  and  no  sound  of  friction  could  any  longer  be  heard 
except  quite  at  the  base  of  the  heart.  But  on  the  21st  there 
was  some  return  of  catching  pain  in  the  left  mammary  region, 
and  the  stethoscope  revealed  incipient  endocardial  inflammation. 
Eight  leeches  were,  therefore,  again  applied  to  the  region  of 
the  heart,  while  the  mercury  was  continued  as  before.  Never- 
theless, an  intense  systolic  murmur,  audible  both  at  the  apex 
and  the  base  of  the  heart,  was  shortly  developed,  the  pulse 
increased  in  frequency,  her  face  again  became  flushed  and  the 
countenance  extremely  anxious,  so  that,  on  the  twenty-fifth,  it 
was  judged  expedient  to  take  eight  ounces  more  blood  from  the 
arm.  Still  the  mischief  continued,  and,  as  by  the  27th  her 
mouth  had  become  slightly  aff"ected  by  the  mercury,  tlie  pills- 
were  omitted,  and  a  third  of  a  grain  of  tartar  emetic  was  given 
every  four  hours,  and  a  blister  applied  to  the  chest.  After 
two  more  nights  of  extreme  restlessness,  a  new  train  of  symp- 
toms presented  themselves.  Her  pupils  became  exceedingly 
dilated,  the  eyes  rolled  wildly,  and  she  was  greatly  excited  in 
her  manner.  As  the  pulse  was  quick  and  weak,  and  jerking, 
the  antimony  was  omitted,  and  half  a  grain  of  the  acetate  of 
morphia  was  given  twice  a  day.  On  the  30th  it  was  repeated 
every  six  hours.     In  the  evening  of  that  day,  furious  delirium. 


268  AFFECTIONS    OF   THE    BKAIN 

supervened,  and  was  accompanied  on  the  following  day  by 
violent  tetanic  spasms,  Avhich  gave  rise,  amonrr  other  actions, 
to  firm  clinching  of  the  fingers.  In  spite  of  morphia  and 
digitalis,  which  were  now  given  in  full  doses  every  four  hours, 
and  of  calomel,  which  was  again  administered  freely  with  the 
view  of  arresting  the  progress  of  the  endocarditis,  while  ice 
was  applied  to  the  head,  the  delirium  continued  incessant  up 
to  the  6th  of  November,  when  she  seemed  thoroughly  ex- 
hausted and  lay  motionless  on  her  back,  with  the  pupils 
exceedingly  dilated,  her  mouth  open,  the  tongue  half  pro- 
truded, dry,  and  brown,  and  the  pulse  rapid,  feeble,  irregular, 
and  intermittent.  Indeed,  she  appeared  tobe  sinking;  but 
she  was  made  to  swallow  some  strong  beef  tea,  and  was  given 
half  a  drachm  of  Hoffmann's  ether,  and  a  quarter  of  a  grain 
of  morphia.  Under  the  influence  of  this  medicine,  which  Avas 
repeated  every  three  hours,  symptoms  of  improvement  soon 
began  to  manifest  themselves.  The  pulse  rallied,  and  again 
she  began  to  talk  and  rave.  By  the  10th,  however,  the  deli- 
rium had  greatly  subsided,  and  she  had  obtained  a  few  hours' 
sleep.  By  the  assistance  of  bark,  which  was  now  adminis- 
tered as  well  as  morphia,  the  improvement  was  fully  sus- 
tained. On  the  I3th,  wine  was  given  in  addition  to  the  medi- 
cine, and,  again,  a  marked  improvement  was  observed.  She 
became  more  tranquil  and  less  flushed,  the  pulse  became 
gradually  steadier  and  fuller,  and  the  heart" s  sounds  clearer. 
By  the  15th,  a  slight  systolic  valvular  murmur  alone  remained; 
the  pulse  had  fallen  to  100,  and  was  soft  and  regular,  the 
tongue  was  moist  and  almost  clean,  and  her  appetite  tolerably 
good.  But  her  mental  faculties  had  not  yet  regained  their 
proper  balance.  She  would  protrude  her  tongue  when  bid  to 
do  so,  but  she  talked  incessantly  and  incoherently,  and  often- 
times santT  snatches  of  various  sonsis  strung  together  in  an 
unconnected  manner.  In  this  half-maniacal,  half-idiotic  state, 
in  which  she  was  at  times  so  violent  as  to  require  a  strait- 
waistcoat,  and  at  others  was  only  troublesome  and  mischiev- 
ous, she  remained  until  the  24th,  when,  after  a  good  night's 
rest,  fhe  became,  for  the  first  time,  decidedly  more  tranquil.  . 

By  the  27th,  under  the  influence  of  a  nourishing  diet,  and  the         ■I 


AS    CONSEQUENCES    OF    ACUTE    RHEUMATISM.  269 

continued  use  of  stimulants  and  sedatives,  she  had  so  far  im- 
proved that,  although  still  excitable  and  strange  in  her  man- 
ner, she  was  allowed  to  dress  and  get  up  during  the  day,  and 
from  this  time  her  progress  toward  recovery  was  steady.  On 
the  14th  of  December  she  left  the  Hospital  to  go  for  a  short 
time  to  the  Sanatorium  at  Carshalton.  A  slight  i^ystolic  mur- 
mur, most  audible  toAvard  the  apex  of  the  heart,  alone  re- 
mained to  tell  the  tale  of  her  fearful  cardiac  seizure ;  she  no 
longer  suffered  any  pain  or  uneasiness  in  the  region  of  the 
heart,  and,  although  weak,  she  was  daily  regaining  strength. 

How  beautifully  does  this  case  illustrate  and  explain *the 
nature  of  the  delirium  in  many  of  these  instances  !  And  how 
suggestive  is  it  of  the  appropriate  treatment !  A  poor,  thin, 
ill-conditioned  girl,  exhausted  by  work,  and  weakened  by  the 
occurrence  of  four  attacks  of  rheumatic  fever,  within  the  short 
space  of  two  years,  is  bled  to  the  extent  of  a  pint  for  the  relief 
of  symptoms  occasioned  by  a  poison  engendered  in  the  system 
by  faulty  assimilation.  What  so  likely  to  augment  the  mis- 
chief, to  impoverish  her  blood,  already  poor  and  deficient  in 
colored  corpuscles,  and  to  exalt  the  excitability  of  the  heart, 
the  brain,  and  the  system  generally !  As  might  have  been 
expected,  the  heart,  damaged,  as  it  were,  and  rendered  irrita- 
ble by  the  Avithdrawal  of  its  natural  and  necessary  stimulus, 
became  unusually  susceptible  of  morbid  influences,  and  suc- 
cumbed under  the  irritation  of  the  rheumatic  poison.  Peri- 
carditis commenced,  and,  for  the  relief  of  that  inflammation,  it 
was  judged  expedient  to  abstract  more  blood,  and  employ  other 
active  and  depressing  remedies.  Their  influence  on  tlio  local 
action  was  soon  beneficially  exerted,  and  the  inflammation  was 
checked.  But  ere  long  it  broke  out  in  a  new  quarter.  No 
sooner  was  the  pericardial  inflammation  subdued,  than  endo- 
carditis commenced  with  extreme  violence ;  with  such  severity, 
indeed,  that  it  was  again  deemed  necessary  to  have  recourse  to 
leeches  and  general  blood-letting,  and  to  recommence  the  ad- 
ministration of  lowering  medicines.  Again  the  beneficial  in- 
fluence of  the  remedies  over  the  course  of  the  cardiac  mischief 
was  clearly  manifested,  but  the  brain  began  to  sympathize  Avith 
the  general  distress ;  it  had  sustained  its  functions  in  spite  of 


270  AFFECTIONS   OF   THE    BRAIN 

the  attack  of  pericarditis,  and  for  eight  days  after  the  invasion 
of  endocarditis,  but  it  gave  way  at  length  under  the  extreme 
disturbance  which  its  nutrition  had  undergone.  The  blood 
which  supplied  it  had  long  been  vitiated  and  impoverished; 
the  heart  which  circulated  that  blood  had  been  rendered  inca- 
pable of  performing  its  work  properly  by  an  attack  of  inflamma- 
tion, both  on  its  external  and  internal  surface;  a  large  quantity 
of  tl  e  blood,  which,  vitiated  as  it  was,  had  been  the  only  source 
of  nourishment  to  the  nervous  centers,  had  been  withdrawn  with 
the  view  of  arresting  the  rheumatism  and  checking  the  prog- 
res^  of  the  cardiac  inflammation,  and  medicines  of  a  most  de- 
pressing character  had  been  freely  administered  for  the  same 
purpose.  No  Avonder  that,  under  such  a  combination  of  cir-" 
cumstances,  the  cerebral  structures  should  have  exhibited  some 
token  of  deranged  function.  At  first,  slight  wandering  only 
was  observed  at  night,  together  with  wildness  of  manner  and 
expression,  but  this  was  speedily  followed  by  active  delirium, 
and  by  more  or  less  convulsive  action.  Morphia  and  digitalis 
administered  freely,  and  the  constant  application  of  ice  to  the 
head,  failed  utterly  in  afi'ording  relief  to  these  symptoms,  as  did 
also  calomel  in  full  and  repeated  doses.  After  a  time,  however, 
it  became  obvious  that  the  symptoms  were  referable  to  "excite- 
ment without  power,"^  and  morphia  was  therefore  resorted  to 
again  in  combination  with  sulphuric  ether.  The  stimulant  in 
combination  with  the  sedative  at  once  effected  what  the  latter, 
by  itself,  had  proved  incapable  of  doing.  The  brain  had  long 
been  subjected  to  depressing  influences,  and  required  its  failing 
energies  to  be  roused,  as  well  as  its  abnormal  irritability  sub- 
dued and  tranquilized,  and  as  day  by  day  this  was  more  fully 
eff"ected  by  means  of  nourishment,  stimulants,  and  sedatives,  it 
became  apparent  how  great  was  the  benefit  derived.  The 
brain  gradually  reassumcd  more  and  more  of  its  healthy  func- 
tions in  proportion  as  the  pulse  betokened  a  return  of  power. 
Without  entering  largely  into  the  detail  of  cases  which  in 

1  This  expression,  which  serves  admirably  to  explain  the  real  nature  of  the 
symptoms,  was  first  applied,  I  believe,  by  Dr.  Gooch,  to  a  peculiar  form  of 
puerperal  mania. 


AS    CONSEQUENCES    OF    ACUTE    RHEUMATISM.  271 

their  repetition  can  serve  no  practical  end,  I  will  briefly  narrate 
such  particulars  of  one  or  two  as  may  tend  to  throw  light  upon 
the  subject  of  rheumatic  delirium,  and  to  illustrate  some  of  the 
facts  already  mentioned.  And  first,  in  regard  to  the  rarest  of 
all  forms  of  head  afifection  occurring  in  connection  Avith  rheu- 
matism, that,  namely,  in  which  the  brain  or  its  membranes  are 
inflamed. 

A  man  who  had  long  suff'ered  from  rheumatism  was  admitted 
into  St.  George's  Hospital,  under  the  care  of  Dr.  Seymour, 
with  his  joints  inflamed  and  swollen.  One  day  his  knees,  which 
had  been  greatly  swollen,  became  very  much  smaller  and  flaccid, 
and,  coincidently  with  the  subsidence  of  the  swelling,  he  com- 
plained of  pain  in  the  head,  became  paralyzed  on  one  side,  and 
expired  in  the  course  of  thirty-six  hours.  On  opening  his  body 
a  large  quantity  of  greenish-looking  purulent  matter  was  found 
smeared  over  the  greater  part  of  the  surface  of  the  left  hemis- 
phere, and  there  was  considerable  effusion  into  the  ventricles.' 
So,  also,  in  a  case  of  Dr.  Watson's.  A  female  patient,  who  had 
rheumatic  fever  and  subsequent  cerebral  symptoms,  died  in  the 
Middlesex  Hospital;  and  upon  examination  of  the  brain,  un- 
equivocal pus  was  found  smeared  over  the  hemispheres.^  So, 
again,  in  a  case  reported  by  Dr.  Fife,  of  Newcastle-upon-Tyne." 
The  patient,  a  man  36  years  of  age,  after  suffering  for  some 
days  from  acute  rheumatism,  was  seized  with  delirium  and 
unequivocal  symptoms  of  cerebral  inflammation.  Life  contin- 
ued for  five  days  longer,  and  throughout  that  period  there  was 
either  muttering  delirium  or  a  state  of  perfect  coma.  On  the 
fifth  day,  at  noon,  he  died ;  and  dissection  showed  the  mem- 
branes of  the  brain  covered  with  lymph  and  pus,  the  vascu- 
larity of  the  brain  enormously  increased,  and  the  lateral 
ventricles  distended  with  serum — sufficient  indications  of  true 
inflammation. 

In  these  three  cases,  and  indeed  in  all  similar  instances  of 
which  I  can  find  records,  the  cerebral  inflammation  does  not 

1  Dr.  Seymour's  Clinical  Lecture.     ■■  Medical  Gazette,"  vol.  xix. 

2  Quoted  in  Dr.  Todd's  Lutnleian  Lectures  for  1850. 
*  "  Medical  Gazette,"  vol.  xxix,  p.  lo:i. 


272  AFFECTIONS    OF    THE    BRAIN 

appear  to  have  been  a  simple  extension  of  the  disease,  but  to 
have  been  excited  by  the  concentration  of  the  rheumatic  virus 
upon  the  brain  in  consequence  of  the  sudden  subsidence  of 
articular  inflammation. 

Inflammation  of  the  brain,  however,  as  ah'eady  stated,  is  a 
rare  accompaniment  of  acute  rheumatism  ;  the  head  sj'raptoms 
observed  in  the  course  of  that  disease  being  more  commonly 
symptomatic  of  pericarditis,  endocarditis,  or  acute  pleurisy. 
Two  of  the  cases,  (Nos.  1  and  3.)  the  outlines  of  which  are 
given  in  a  former  chapter,^  afford  an  illustration  of  this  import- 
ant fact,  as  do  also  many  cases  which  others  have  put  on  record. 
Thus,  one  of  the  children  of  Christ's  Hospital,  who  was  suff'er- 
ing  from  acute  rheumatism,  was  attacked,  on  the  third  day  of 
his  illness,  with  delirium  and  convulsions.  The  attack  was 
sudden,  with  great  heat  of  skin  and  frequency  of  pulse,  and, 
in  the  opinion  of  all  who  saw  the  case,  it  Avas  an  instance  of 
the  severest  inflammation  of  the  brain.  The  boy  pointed  to 
his  forehead  as  the  seat  of  pain.  On  the  fourth  day  he  sank 
into  a  state  of  insensibility  and  died,  and  upon  dissection,  not 
a  vestige  of  disease  was  found  within  the  cranium,  but  the 
heart  was  exclusively  the  seat  of  mischief,  and  no  other  part  of 
the  body  exhibited  the  slightest  morbid  appearance.  The  dis- 
ease of  the  heart  was  not  confined  to  its  investing  membrane. 
It  was  the  most  intense  inflammation  pervading  the  pericardium 
and  the  muscular  structure."  So,  again,  Dr.  Richard  Bright 
reports  of  a  young  man  whom  he  attended  in  the  year  1836. 
He  had  been  suff'ering  from  acute  rheumatism  six  days,  when 
spasmodic  symptoms  appeared,  increased  rapidly  in  severity, 
and  were  shortly  accompanied  by  delirium.  This  ultimately 
became  so  violent  that  it  was  found  necessary  to  put  the  unfor- 
tunate sufferer  under  restraint.  He  died  at  the  expiration  of 
three  weeks,  and  on  dissection  the  brain  was  found  perfectly 
healthy,  and  the  pericardium  and  endocardium  presented  une- 

1  Ciip.  YII.  pp.  100.  191. 

2  The  particulars  of  this  case  are  detailed  by  Mr.  Stanley,  in  vol.  vii  of  the 
■'  Medico-Chir.  Trans." 


AS    CONSEQUENCES    OF   ACUTE   RHEUMATISM.  273 

quivocal  signs  of  recent  active  inflammation.^  Dr.  Watson  has 
placed  several  cases  on  record,  in  one  of  which  the  endocardium 
alone  was  the  seat  of  inflammation.^  In  another,  a  girl,  17 
years  of  age,  after  suffering  from  acute  rheumatism  between 
two  and  three  weeks,  became  so  furiously  maniacal  that  it  was 
found  necessary  to  confine  her  by  means  of  a  strait-waistcoat. 
She  continued  in  the  same  state  until  she  died ;  yet  the  brain 
was  found  perfectly  healthy,  and  the  only  discoverable  organic 
lesion  was  in  the  pericardium,  which  was  universally  coated,  on 
its  internal  surface,  by  a  thick  layer  of  recent  lymph. ^  Dr. 
George  Burrows  and  Dr.  Todd  have  also  met  with  cases  in 
point.  The  former  tells  us  of  a  shop-boy,  who,  after  seven  days' 
illness,  expired  in  a  state  of  restlessness  and  delirium,  and 
upon  examination  of  the  body  the  pericardium  was  found  cov- 
ered with  a  net-work  of  recent  lymph,  while  "  upon  the  anterior 
surface  of  the  left  ventricle  of  the  heart,  there  was  a  white  spot 
about  a  quarter  of  an  inch  in  diameter,  which  appeared  to  be 
formed  by  concrete  pus."^  The  latter  reports  that  a  young 
woman,  after  suffering  for  some  days  from  rheumatic  fever,  was 
seized  with  delirium,  and  in  a  few  hours  afterward  had  a  convul- 
sive fit,  succeeded  by  coma  and  death ;  yet  the  closest  examination 
of  the  parts  after  death,  while  it  exposed  extensive  inflammation 
of  the  pericardium,  could  not  detect  a  trace  of  inflammation  of 
the  brain,  which,  together  with  its  membranes,  were  unusally 
pale.'* 

The  third  class  of  cases,  or  those  in  which  rheumatic  delirium 
is  unaccompanied  by  internal  local  inflammation,  are  of  much 
rarer  occurrence,  inasmuch  as  when  the  constitutional  derange- 
ment is  so  great  as  to  occasion  disturbance  of  the  nervous  cen- 
ters, the  rheumatic  poison  is  present  in  large  quantity,  and 
usually  gives  rise  to  cardiac  inflammation.  But,  though  com- 
paratively rare,  they  do  sometimes  occur.  Dr.  Todd  has  made 
mention  of  some,  and  I  have  myself  seen  eight,  in  which  slight 

1  "  Medico-Chir.  Trans.,"  toI.  xxii. 

2  "  Medical  Gazette,"  vol.  xvi,  p.  93. 

3  "  Practice  of  Physic,"  ed.  1,  vol.  ii,  p.  276. 

*  "  On  Disorders  of  the  Cerebral  Circulation,"  p.  188. 
5  Lumleian  Lectures,  published  in  the  "  Lancet"  for  1852. 


274  AFFECTIONS    OF   THE    BRAIX 

wandering  or  delirium  lias  arisen,  and  has  continued  for  several 
hours,  although  the  stethoscope  has  failed  in  detecting  the 
slightest  mischief  within  the  chest,  and  the  general  symptoms 
have  been  inconsistent  with  the  occurrence  of  inflammatory 
action  within  the  cranium.  One  instance  has  lately  occurred 
to  me  in  which  a  fatal  result  ensued.  The  patient  was  a  gen- 
tleman, 39  years  of  age,  who  had  been  weakly  and  out  of 
health  for  many  months  prior  to  the  commencement  of  the 
attack.  He  was  seized  with  S3'mptoms  of  acute  rheumatism  on 
the  15th  of  February,  1856,  and  I  was  called  in  consultation 
by  my  friend  Mr,  Kesteven,  on  the  22d  instant,  the  eighth 
day  of  the  attack.  The  patient  was  low  and  irritable,  and  his 
complaint  of  pain  was  out  of  all  proportion  to  the  apparent 
severity  of  the  articular  inflammation ;  but  in  other  respects 
there  was  nothing  worth  noting  until  the  26th  instant,  when, 
after  forty-eight  hours  of  almost  entire  sleeplessness,  he  became 
more  than  ever  restless,  tremulous,  and  excited.  These  symp- 
toms passed  off  in  the  morning  of  the  27th,  but,  in  spite  of 
opium,  reappeared  with  increased  violence  toward  evening. 
On  the  28th,  he  was  sensible  when  spoken  to,  but  restless  and 
excited  to  the  highest  degree,  talking  incessantly,  moving  rap- 
idly about  in  bed,  and  using  his  hands  to  pull  himself  up,  in 
utter  disregard  of  the  swollen  and  painful  condition  of  the  left 
wrist-joint.  His  head  was  not  hot,  and  he  declared  that  it  was 
and  ever  had  been  perfectly  free  from  pain.  Occasionally  he 
could  see  only  half  of  any  object  at  which  he  was  looking  ;  his 
pupils  were  much  dilated,  but  acted  under  the  stimulus  of 
strong  light ;  the  pulse  was  rapid,  feeble,  and  fluttering,  the 
tongue  dry,  but  not  much  coated.  His  heart,  which  had  been 
examined  daily,  and  twice  a  day,  still  remained  perfectly  free 
from  mischief.  Diffusible  stimulants  and  sedatives  were  given, 
but  without  effect.  With  the  approach  of  evening,  the  symp- 
toms of  excitement  again  increased,  he  could  with  difficulty  be 
kept  in  bed,  and  he  talked  incessantly  and  in  a  most  incoherent 
manner.  About  12  p.m.  the  restlessness  subsided,  he  became 
calm  and  collected,  said  he  felt  he  should  die,  called  for  his 
wife  and  children,  and  gradually  expired  about  half-past  one 


AS    CONSEQUENCES    OF   ACUTE    RHEUMATISM.  275 

in  the  morning  of  the  2Uth.  My  friend  Mr.  Pyle,  of  Oxford 
Terrace,  Hyde  Park,  has  favored  me  with  the  particulars  of 
another  case.  A  gentleman,  while  laboring  under  symptoms 
of  acute  articular  rheumatism,  became  affected  by  tetanic 
spasms,  opisthotonos,  and  convulsions.  Delirium  of  a  violent 
character  supervened,  and  the  unfortunate  sufferer  could  with 
difficulty  be  kept  in  bed.  Nevertheless,  Dr.  Latham  and  Mr. 
Pyle,  who  both  examined  him  daily  by  the  stethoscope,  failed 
in  detecting  anything  abnormal  in  the  condition  of  the  heart, 
the  lungs,  or  the  pleur?e,  and  were  both  persuaded,  from  the 
character  of  the  accompanying  symptoms,  that  no  inflammation 
had  been  set  up  in  the  brain  or  spinal  cord.  In  all  the  cases 
alluded  to,  the  patient's  recovery,  or  the  absence  of  post- 
mortem investigation,  has  rendered  it  impossible  to  obtain  more 
than  presumptive  proof  of  the  non-existence  of  internal  inflam- 
mation ;  but  cases  are  occasionally  met  with,  in  which  the 
effects  of  cerebro-spinal  irritation  are  manifested  by  furious 
delirium  and  violent  spasmodic  action,  terminating  only  with 
the  patient's  life,  and  in  which,  therefore,  it  is  possible,  by  a 
post-mortem  examination,  to  obtain  positive  evidence  as  to  the 
absence  of  carditis,  and  of  every  other  form  of  internal  inflam- 
mation. Such  a  case  occurred  at  St.  George's  Hospital,  in  the 
year  1850.  It  has  been  already  referred  to  in  a  previous  chap- 
ter ;^  but  the  inferences  deducible  from  it  are  of  such  import- 
ance, that  I  do  not  hesitate  to  give  it  in  detail. 

Ann  Amess,  aet.  21,  servant  of  all  work,  who  had  suffered 
from  slight  rheumatism  a  year  before,  was  seized,  on  the  17th 
of  January,  with  wandering  pains  in  the  limbs,  accompanied 
by  redness  and  swelling  of  the  joints,  for  which  she  put  herself 
under  medical  treatment  on  the  19th.  On  the  24th,  she  was 
admitted  into  Pepy's  Ward,  under  the  care  of  my  colleague, 
Dr.  Bence  Jones.  There  were  redness  and  sAvelling  in  some  of 
her  joints,  with  excessive  pain  in  all,  and  she  was  complaining 
of  a  catching  pain  in  the  cardiac  region.  Her  face  was 
exceedingly  flushed,  and  her  pulse  quick,  but  by  no  means 
sharp.  A  soft  systolic  murmur,  which  increased  in  intensity 
1  Cap.  VII,  p.  201. 


276  AFFECTIONS    OF   THE    BRAIN 

in  tlie  course  of  three  days,  was  audible  over  the  base  of  the 
heart,  but  this,  from  its  position  and  the  direction  in  which  it 
was  heard,  was  regarded  as  having  an  anremic  origin.  In  short, 
no  evidence  coukl  be  obtained  of  mischief  within  the  chest. 
The  perspiration  was  most  profuse,  and  on  the  27th,  a  crop  of 
miliary  vesicles  appeared  upon  the  chest.  No  other  symptom 
worthy  of  note  presented  itself,  until  the  evening  of  the  31st, 
when  the  nurse  observed  that  the  patient  was  restless,  and 
rather  flighty  and  delirious.  These  symptoms  subsided  in  the 
morning,  but  only  to  reappear  on  the  following  evening  with 
increased  violence  and  obstinacy.  They  did  not  now  subside 
toward  morning :  the  dawn  of  day  showed  her  restless,  trem- 
ulous, and  excited,  and,  with  the  approach  of  evening,  she 
became  still  more  excited  and  delirious.  Morphia  had  been 
given  in  vain :  and  laudanum,  in  full  doses,  was  now  resorted 
to,  with  the  view  of  tranquilizing  the  nervous  centers :  but  the 
head  symptoms  rapidly  increased  in  severity  ;  she  became  vio- 
lently delirious,  so  that  she  had  to  be  held  in  bed  ;  she  then 
lapsed  into  a  state  of  coma,  and  expired  on  the  morning  of  the 
3d  of  February.  When  coma  supervened,  Mr.  llammerton, 
the  resident  medical  officer,  bled  her  to  six  ounces,  and  the 
blood  was  neither  buffed  nor  cupped. 

After  death,  dissection  showed  the  brain  and  its  membranes 
rather  drier  than  usual,  but  without  any  other  remarkable 
appearance  ;  the  lungs  congested,  but  otherwise  healthy,  and 
the  pleurae  adherent  here  and  there  to  the  parietes  of  the  chest 
by  old  and  firm  adhesions,  but  exhibiting  no  trace  of  recent 
inflammation.  The  pericardium  contained  about  two  ounces  of 
serum  ;  the  heart  and  its  valves  loere  perfectly  healthy,^  its  right 
cavities  contained  fibrinous  coagula.  The  peritoneal  cavity 
contained  a  small  quantity  of  turbid  serum.  The  liver  and 
pancreas  Avere  healthy  ;  the  spleen  soft  and  flabby  ;  the  kidneys 

1  Such  at  least  is  the  record  of  the  post-mortem  appearance  preserved  by  our 
Curator,  in  the  Museum  of  the  Hospital,  and  it  serves  to  show  the  extent  of 
"  the  very  slightest  roughness''^  which,  in  the  record  of  the  same  case,  in  the 
"  Transactions  of  the  Pathological  Society,"  is  mentioned  as  having  been 
observed  at  one  spot  on  the  surface  of  one  of  the  auricles.  There  was  not  the 
slightest  injection  of  the  pericardial  membrane. 


AS   CONSEQUENCES    OF    ACUTE   RHEUMATISM.  277 

slightly  congested,  especially  the  right,  but  perfectly  healthy 
in  appearance.  The  synovial  membrane  of  both  knee-joints 
■was  highly  vascular,  and  their  cavities  contained  a  quantity 
of  turbid,  yellow  serum,  in  which  masses  of  lymph  were 
floating. 

Here,  then,  is  a  remarkable  case  in  point.  The  patient  was 
a  servant  of  all  work,  who,  as  I  am  informed  by  my  colleague, 
Mr.  Keate,  who  sent  her  into  the  hospital,  had  been  sitting  up 
at  night  for  some  time,  engaged  in  nursing  an  invalid.  He  told 
me,  when  she  was  first  admitted,  that  she  was  much  exhausted 
by  her  labors;  and  the  loud  anemic  murmur  which  was  heard 
throughout  the  attack,  and  the  crop  of  sudamina  which  very 
shortly  appeared,  attested  the  correctness  m)^  his  judgment. 
Then  came  the  delirium,  indicative  of  the  irritability  consequent 
on  that  exhaustion ;  and  in  direct  corroboration  of  the  evidence 
afl"orded  by  the  symptoms,  the  blood  drawn  from  the  arm  was 
neither  buffed  nor  cupped.  After  death  the  chain  of  evidence 
was  completed.  The  brain  and  its  meninges,  the  lungs  and 
their  envelopes,  the  heart  and  its  membranes,  both  external 
and  internal,  were  closely  and  carefully  examined,  but  no  trace 
of  inflammation  could  be  found,  and  the  ftict  became  apparent 
that  the  symptoms  observed  during  life  were  due  to  the  morbid 
blood  acting  upon  nervous  centers,  rendered  more  than  usually 
susceptible  of  irritation  by  the  exhaustion  to  which  the  patient 
had  been  subjected.  The  delirium  was  obviously  referable 
neither  to  congestion  nor  inflammation,  but  to  excitement  with- 
out power. 

In  illustration  of  the  severity  which  spinal  symptoms  may 
assume  in  connection  with  acute  rheumatism,  the  following 
very  remarkable  case  may  be  cited  :  A  boy,  16  years  of  age, 
was  admitted  under  the  care  of  M.  Bouillaud,  suffering  from 
severe  cramps  and  tetanic  spasms,  affecting  almost  every  part 
of  his  frame.  It  appeared  that  he  had  been  attacked  with 
acute  rheumatism  about  a  fortnight  previous  to  his  admission  ; 
convulsive  contraction  of  the  fingers,  after  a  time,  supervened  ; 
and  subsequently,  tetanic  spasms  commenced  in  various  parts 
of  the  body. 


278  AFFECTIONS    OF    THE    BRAIN 

When  first  seen  by  M.  Bouillaud,  liis  countenance  was  most 
anxious,  his  eyes  were  fixed,  and  the  pupils  dilated.  His  in- 
tellect was  unobscured,  but  the  voice  was  rendered  trembling 
by  the  constant  sobs  called  forth  by  the  severity  of  the  cramps 
in  his  limbs.  No  part  of  his  body  was  free  from  pain.  The 
mouth  could  hardly  be  opened,  so  firmly  and  spasmodically  was 
it  closed ;  his  fingers,  arms  and  forearms,  toes  and  feet,  were 
violently  contracted,  and  the  muscles  of  the  abdomen,  no  less 
than  those  of  the  extremities,  were  hard  as  stone  during  the 
spasms.  Added  to  all  this  suffering  was  a  constant  sense  of 
sufi'ocation.  In  spite  of  general  and  local  blood-letting,  toge- 
ther with  warm  baths  and  the  internal  administration  of  opium, 
the  attacks  of  spasm  recurred  continually;  symptoms  of  trismus 
became  more  urgent  and  distressing;  the  least  attempt  to  swal- 
low very  greatly  aggravated  his  suffering ;  and  he  died,  ex- 
hausted, on  the  tenth  day  from  the  first  appearance  of  spasms 
in  the  fingers. 

The  spasms  had  been  regarded  as  symptomatic  of  inflamma- 
tion of  the  spinal  cord,  but  dissection  revealed  an  injected 
condition  of  the  pericardium,  and  within  its  cavity  about  two 
ounces  of  pure  creamy  greenish  pus,  while  in  the  brain  and  its 
meninges  a  slight  congestion  only  was  observed,  and  in  the 
spinal  cord  and  its  membranes  there  was  no  unusual  appear- 
ance beyond  a  small  circumscribed  spot  of  softening  at  the 
superior  enlargement  of  the  cord.^ 

Death,  however,  is  not  a  necessary  consequence  of  cerebro- 
spinal irritation,  and,  therefore,  however  alarming  the  symp- 
toms, our  prognosis  should  be  extremely  guarded.  I  have 
already  narrated  the  particulars  of  one  case"  which  fell  under 
m}'^  own  observation  in  which  recovery  took  place  under  cir- 
cumstances which  almost  precluded  the  possibility  of  such  an 
event ;  and  an  equally  favorable  issue  occurred  in  another  case 
which  came  under  the  care  of  Dr.  Edward  Dewees,  at  the 
Coventry  and  Warwickshire  Hospital.  A  young  woman,  set. 
19,  was  attacked  on  the  12th  of  January  with  feverishness, 
accompanied,  on  the  following  day,  by  redness  and  swelling  of 

1  Bouillaud's  "  Traite  des  Maladies  du  Coeur,"  torn,  i,  p.  333, 

2  Page  206,  of  this  Treatise. 


AS    CONSEQUENCES    OF   ACUTE    RHEUMATISM.  279 

the  various  joints,  and  by  other  characteristic  symptoms  of 
acute  rheumatism.  She  manifested  no  untoward  symptom 
until  tlie  17th,  when  her  heart  gave  tokens  of  commencing 
inflammation,  and  she  became  restless,  talkative,  and  flighty. 
On  the  18th  an  exocardial  friction-sound  was  heard,  as  was 
also  a  loud  systolic  murmur ;  and  altogether,  she  was  much 
worse.  She  had  not  slept,  and  "she  was  so  violent  that  it 
required  two  or  three  persons  to  keep  her  in  bed."  "  The 
right  arm  was  in  a  state  of  constant  jactitation,  so  that  it  was 
never  still  for  an  instant ;  the  right  leg  was  similarly  aff'ected, 
but  to  a  less  extent ;  at  times,  however,  this  state  became  ag- 
gravated into  one  of  general  convulsions  of  a  tetanic  character." 
She  continued  in  the  same  maniacal  condition  for  nine  days, 
during  which  time  the  convulsions  continued  incessantly,  and 
she  had  no  sleep.  "  On  the  23d  she  suddenly  jumped  up,  and 
fell  out  of  bed,  her  forehead  coming  in  contact  with  the  floor." 
On  this  she  became  comatose,  but  the  coma  was  relieved  by  the 
application  of  a  few  leeches  to  the  head.  "  The  treatment 
throughout  consisted  of  bleeding,  general  and  local,  repeated 
blistering,  and  mercurialization ;"  and  as  soon  as  the  system 
was  brought  fully  under  the  influence  of  mercury,  the  severe 
symptoms  were  materially  alleviated.  On  the  l3th  of  Febru- 
ary she  was  convalescent,  the  systolic  murmur  alone  remaining,^ 
Thus,  then,  where  delirium,  convulsions  and  coma  occur  in 
the  course  of  acute  rheumatism,  the  first  point  to  be  ascer- 
tained is  their  connection  or  non-connection  with  any  internal 
local  inflammation.  If  we  are  unable  to  discover  any  signs  of 
cardiac  or  pulmonary  inflammation,  and  from  the  absence  of 
symptoms  of  cerebral  or  spinal  inflammation  are  led  to  regard 
the  disturbance  of  the  nervous  centers  as  functional  only,  then, 
as  in  delirium  tremens,  or  erysipelas,  the  invasion  of  head 
symptoms  should  be  a  signal  to  support  and  tranquilize  our 
patient  by  the  administration  of  nourishment,  stimulants,  and 
opiates.  In  no  case  is  opium,  in  combination  with  diff"usible 
stimulants,  of  greater  service  than  in  this  atonic  form  of  deli- 
rium  ;  and  in  none  is  venesection  more  prejudicial.  If,  on  the 
1  '•  Medical  Gazette,"  new  series,  vol.  x,  p.  457. 


280  AFFECTIONS   OF   THE   BRAIN 

Other  hand,  we  detect  active  cardiac  or  puhiionary  mischief,  or 
from  the  presence  of  symptoms  of  inflammation  of  the  brain, 
such  as  excessive  heat  of  head,  injection  of  the  eye,  intoler- 
ance of  light,  and  vomiting  occurring  coincidently  with  hard- 
ness of  the  pulse,  and  other  symptoms  of  acute  inflammation, 
we  are  led  to  suspect  the  existence  of  cerebral  inflammation, 
then  are  we  justified  in  having  recourse  to  such  antiphlogistic' 
or  other  remedial  measures,  as  appear  called  for  by  the  symp- 
toms in  each  particular  instance.  In  such  cases  our  efi"orts 
should  be  directed  to  the  speedy  subjugation  of  those  actions 
going  on  within  either  the  chest  or  the  cranium,  which  expe- 
rience has  proved  to  be  intimately  connected  with  the  occur- 
rence of  cerebro-spinal  symptoms,  and  on  the  cessation  of 
which  it  teaches  us  to  believe  we  may  reasonably  expect  their 
subsidence.  But  as  it  is  notorious  that  venesection  and  other 
depletory  measures  have  a  tendency  to  reduce  the  proportion 
of  red  corpuscles  in  the  blood,'  and  to  produce  a  condition 

'  See  Note.  p.  93.  of  this  Treatise.  MM.  Becquere  land  Rodier,  after  ana- 
lyzing their  experiments,  as  to  the  effect  produced  by  venesection  on  the 
blood,  sum  up  by  stating,  "  in  short,  the  efl'ect  of  venesection  is  to  cause  a 
great  diminution  of  the  corpuscles."  (Simon's  "  Chemistry,"  vol.  i,  p.  250.) 
In  confirmation  of  this  fact,  I  may  cite  some  experiments  detailed  in  Dr. 
Todd's  Lumleian  Lectures  for  1850  :  "  A  large  and  well-nourished  dog,  appar- 
ently in  perfect  health,  was  fed  daily  on  two  pounds  of  meat  and  a  quart  of 
milk.  He  was  bled  on  four  successive  days,  to  the  extent  of  six  ounces  each 
day.  and  the  blood  carefully  analyzed.  The  blood  drawn  on  the  first  bleed- 
ing, on  the  6th  of  April,  contained  in  1000  parts — 

14285  Corpuscles, 

2-45  Fibrin, 
783-79  Water. 
That  on  the  second  bleeding,  on  the  7th  of  April,  exhibited  a  diminution  of 
the  corpuscles,  and  an  increase  of  the  water  to — 

11.3-54  Corpuscles, 

4-72  Fibrin, 
810-89  Water. 
On  the  third  bleeding,  on  the  8th  of  April,  the  corpuscles  had  again  dimin- 
ished, and  the  water  increased  to— 

110-58  Corpuscles, 

4-34  Fibrin, 
815-18  Water. 
And  on  the  fourth  bleeding,  there  were  found— 
106*96  Corpuscles, 

3-99  Fibrin, 
813-04  Water. 


AS    CONSEQUENCES    OF    ACUTE    RHEUMATISM.  281 

favorable   to  the  development  of  delirium  and  convulsions,  we 
should  be  exceedingly  cautious  in  having  recourse   to  their 
employmont,  lest  by  still  further  impoverishing  the  blood,  and 
impairing  the  powers  of  the  constitution,  we  seriously  endan- 
ger our  patient's  recovery.     In  cases  marked  by  evident  symp- 
toms of  cerebro-spinal  inflaynmation,  it  may  be  necessary  to 
have   recourse   to   blood-letting ;  but  if   in  ordinary  cases   of 
rheumatic  carditis  the  expediency  of  venesection  is  question- 
able, much  more  so  is  it  in  those  where  the  nervous  centers 
are  irritable,  and  are  suffering  from  the  effects  of  malnutri- 
tion, arising  from  an  altered  condition  and  an  irregular  sup- 
ply of  blood.     Even  local  depletion,  though  sometimes  expe- 
dient in  such  cases  for  the  relief  of  active  local  inflammation, 
should  be  seldom  practiced  to  any  great  extent.     We  should 
rather  endeavor  to  support  our  patient,  while  aiming  at  the 
relief  of  the  more  urgent  symptoms,  by  means  of  blisters,  mer- 
curials, diuretics,  and  opium.     We  should  economize  strength 
by  administering  opium  in  doses  sufficient  to  relieve  the  pain 
and  tranquilize  the  excited  nervous  centers,  and  at  the  same 
time   support  the  fading  powers  of  the  system  by  means  of 
a  nourishing  and  stimulating  diet.     Thus  Ave  may  check  the 
tendency  to  death,   and  give  our  remedies  time  to  play  their 
part.     By  degrees  as  the  cardiac  inflammation  is  subdued,  the 
fluid  Jeffused  into  the  pericardial  sac  is  reabsorbed,  and  the 
heart  gradually  acquires  greater  freedom  of  action.     Coinci- 
dently  with  this  improvement  in  the  center  of  circulation   a 
corresponding  improvement   is   effected   in  the   blood   by  the 
gradual  elimination  of  the  rheumatic  poison,  and  thus  the  irri- 
tability of  the  nervous  centers  is  lessened,  and  the  symptoms 
gradually   subside.     One    exception    only  exists    to   the    full, 
though  cautious  exhibition   of  opium.     I  refer   to  those  in- 
stances in  which  there  is  a  tendency  to  the  supervention  of 
coma.     In  such  cases  opium  is  not  only  useless,  it  is  decidedly 
prejudicial  to  the  safety  of  the  patient,  who  requires  a  more 
than  usual  amount  of  support  and  stimulus. 

Thus  much  then  for  those  affections  of  the  nervous  system, 
which,  from  time  to  time,  arise  in  the  course  of  ac  ute  rheu- 
19 


282  INFLAMMATION    OF   THE    LUNGS   AND    PLEURA 

matism,   and  cannot  but  prove  a  source    of   perplexity    and 
anxiety. 

Another  complication  which  adds  greatly  to  the  danger 
attendant  upon  this  disease,  is  inflammation  of  the  lungs  and 
their  membranous  coverings;  inflammation  attacking  some- 
times one,  sometimes  another  part  of  the  pulmonary  structure, 
sometimes  invading  all  parts  simultaneously,  producing  dysp- ' 
noea,  suflfocation  and  death.  "  Such  forms  of  pulmonary  in- 
flammation are  portentious  ingredients  in  the  clinical  history 
of  acute  rheumatism,  and  give  a  fearful  interest  to  it,"'  and 
they  are  the  more  formidable  from  the  fact  that  they  gen- 
erally coexist  with  inflammation  of  the  investing  membrane  of 
the  heart.  In  some  instances,  the  pulmonary  inflammation 
may  be  excited  by  simple  contiguity  of  the  affected  structures, 
but  more  generally,  whether  the  attack  be  bronchitis  or  pneu- 
monia, or  whether  it  assumes  the  form  of  pleurisy,  it  is  due  to 
the  same  cause  of  irritation,  the  same  morbific  agent  which 
excites  the  articular  and  cardiac  aff"ections.^  Hence  its  ap- 
pearance is  fraught  with  unusual  danger.  For,  as  the  pri- 
mary cause  of  inflammation  is  difi"used  throughout  the  blood, 
and  consequently  comes  in  contact  with  every  part  of  the  pul- 
monary tissue,  inflammatory  action  is  no  sooner  excited  than 
it  spreads  with  fearful  and  life-destroying  rapidity,  and  as  its 
cause  is  persistent,  so  its  course  is  obstinate  and  little  under 
the  control  of  medicine.  "Whichever  disease  occurred,"  says 
Dr.  Latham,  "  it  always  put  on  a  serious  character,  either 
from  the  mere  magnitude  and  extent,  or  from  the  force  of 
morbid  action,  or  from  the  stage  at  which  it  ultimately  ar- 
rived. In  the  four  instances  of  bronchitis,  the  affection  was 
no  mere  catarrh,  but  an  inflammation  largely  diff'used  through 
both  lungs,  producing  deep  oppression  and  dyspnoea.  Of  the 
two  pleurisies,  one  was  single  and  the  other  double.  The  single 
pleurisy  produced  a  large  eff'usion  into  one  side.  The  double 
pleurisy  produced  a  double  hydrothorax.  Of  the  18  instances 
of  pneumonia,  in  9  the  disease  was  of  one  lung,  and  in  9  it 
was  of  both." 

1  Latham's  "Clinical  Medicine."  vol.  i.  p.  162. 

2  See  note  at  p.  151  of  this  Treatise. 


AS   A   CONSEQUENCE    OF   ACUTE    RHEUMATISM.  283 

My  experience  at  St.  George's  Hospital  tallies  very  closely 
with  that  of  Dr.  Latham  at  St.  Bartholomew's.  He  has  re- 
ported some  form  of  pulmonary  affection  in  24  out  of  18(3 
cases  of  acute  rheumatism,  or,  in  other  words,  in  1  out  of 
every  5*6  cases;  and  of  the  246  cases  of  acute  rheumatism 
which  were  admitted  during  the  time  I  was  medical  Registrar, 
41,  or  exactly  1  in  every  6,  were  complicated  by  some  form 
of  pulmonary  inflammation.  Among  the  cases  which  were 
uncomplicated  by  recent  cardiac  affection,  7  instances  only  of 
pulmonary  inflammation  were  observed;  among  those  which 
were  complicated  by  recent  endocardial  affection  alone,  8  ex- 
amples were  noted:  among  those  accompanied  by  pericarditis 
alone,  7  :  and  among  those  accompanied  by  endo-pericarditis, 
19  occurred.  In  other  words,  some  pulmonary  affection  of  an 
inflammatory  nature  was  observed — 

In     7  out  of  127'  or  in  1  out  of  every  18-1   cases  uncomplicated  bj-  recent 

cardiac  mischief. 

■'      8       "         801      u       I  11  ^0-0  cases    complicated    by    recent 

endocardial  affection  alone. 

"      7       "         12        "       1  "  1-7  cases  complicated  by  exocardial 

inflammation  alone. 

"    19       "         27        "       1  "  1-4  cases  complicated  by  endo-peri- 

carditis. 

In  the  first  class  of  cases,  the  affection  was  in  six  instances 
bronchitis,  in  one  pneumonia. 

In  the  second,  it  was  twice  bronchitis,  four  times  pneumonia, 
and  twice  pleuro-pneumonia. 

In  the  third,  it  was  partly  bronchitis,  partly  pneumonia  in 
four  instances,  pleurisy  in  one  instance,  and  partly  pneumonia, 
partly  pleurisy  in  the  remaining  two. 

In  the  fourth,  it  was  bronchitis  in  one  instance,  pneumonia 
in  ten  instances,  pleurisy  in  three,  and  partly  pneumonia,  partly 
pleurisy  in  the  remaining  five. 

In  almost  all  the  fatal  cases  of  carditis,  either  pleurisy  or 
pneumonia,  or  pleuro-pneumonia,  were  present.^ 

1  The  numbers  127  and  80  each  include  5,  or  half  of  the  cases  in  which  the 
date  of  the  mischief  was  uncertain. 

'•^  For  illustrations  of  this  fact,  see  Cap.  YII,  pp.  l'JO-203,  of  this  Treatise. 


284  INFLAMMATION    OF    THE    LUNGS    AND    TLEVRM 

Formidable,  however,  as  these  numbers  are,  the  proportion 
of  cases  in  which  pulmonary  inflammation  has  arisen  in  acute 
rheumatism,  has  been  even  gieater  in  the  experience  of  others. 
Thus  Dr.  John  Taylor,  of  Iluddersfield,  reports  that  of  11  cases 
of  rheumatic  pericarditis,  pleurisy  was  found  in  5,  and  pneu- 
monia in  5.     In  4  of  the  latter  there  was  pleurisy  as  well.^ 

The  physical  symptoms  of  rheumatic  inflammation  of  the 
lungs  and  pleura,  are  such  as  are  met  with  in  ordinary  pneu- 
monia and  pleurisy,  and  therefore  need  not  be  dwelt  upon  more 
particularly,  nor  is  there  anything  beyond  the  severity  and  in- 
tractability of  the  disease,  which  calls  for  especial  notice.  But 
in  a  diagnostic  point  of  view,  there  is  much  which  demands  our 
serious  attention.  Cases  not  unfrequently  occur  in  w"hich  no 
external  rheumatism  exists,  and  in  which,  nevertheless,  the 
whole  train  of  symptoms  are  doubtless  attributable  to  the  irri- 
tation of  the  rheumatic  poison.  Just  as  cardiac  aff"ection  may 
occur  as  the  Jirst,  and,  for  some  time,  the  oniz/  local  symptom 
of  rheumatism,  so,  also,  I  am  persuaded,  may  bronchitis,  pneu- 
monia, and  pleurisy.  The  cases  referred  to  are  usually  char- 
acterized from  the  first  by  a  red  coated  tongue,  profuse  acid 
perspiration,  and  by  the  strong  empyreumatic  odor  of  rheu- 
matism ;  and  these  symptoms  are  sometimes  so  striking,  that 
in  two  instances  they  have  enabled  me  to  predict  the  accession 
of  a  well-developed  attack  of  articular  rheumatism."^  And  al- 
though the  evidence  of  a  rheumatic  origin  is  seldom  so  strongly 

1  "  Medico-Chir.  Trans.,"  vol.  xxviii,  p.  514. 

2  A  case  of  this  sort  has' recently  occurred  to  me  in  the  person  of  Thomas 
Comber,  who  was  admitted  into  the  York  ward  of  St.  George's  Hospital,  under 
my  care,  on  the  2d  of  February,  1856,  laboring  under  acute  pneumonia.  From 
the  very  commencement  of  his  attack,  he  was  literally  bathed  in  profuse  acid 
perspiration,  emitting  the  peculiar  odor  of  rheumatism,  and  his  tongue  was 
excessively  red  and  coated.  So  marked  were  these  symptoms,  that  I  ques- 
tioned him  as  to  the  existence  of  rheumatic  pains,  and  pointed  out  to  the 
pupils  the  peculiar  character  of  the  symptoms,  as  indicative  of  the  probable 
source  of  the  attack,  and  as  calculated  to  influence  the  treatment.  Through- 
out his  sojourn  in  the  hospital  he  had  no  external  symptom  of  rheumatism, 
but  within  three  days  of  his  discharge  he  was  attacked  with  acute  rheumatic 
S'^-<»llin£r  of  the  joints,  and  was  readmitted  into  the  hospital  on  the  IGih  of 
March,  under  the  care  of  Dr.  Bence  Jones,  suffering  from  a  well-marked  attack 
of  acute  rheumatism. 


AS    A    CONSEQUENCE    OF   ACUTE    RHEUxMATISxM.  285 

marked  as  in  these  instances,  I  am  convinced  bj  the  effect  of 
treatment  in  several  suspicious  cases,  that  the  irritation  of  the 
rheumatic  poison  is  a  much  more  fre([uent  cause  of  pubnonary 
inflammation  than  is  generally  supposed,  and  that  its  influence 
cannot  be  safely  disregarded.  For  in  the  treatment  of  rheu- 
matic inflammation  of  the  lungs,  whether  accompanied  or  unac- 
companied by  articular  pain  and  swelling,  it  must  ever  be  borne 
in  mind  that  the  symptoms  arise  from  no  common  local  cause 
of  irritation.  The  mischief  of  which  they  are  mere  exponents, 
is  excited  and  kept  up  by  a  cause  in  its  nature  persistent,  and, 
indeed,  coexistent,  with  the  duration  of  the  rheumatism,  and 
although  we  may  modify  the  local  action  by  remedies  addressed 
to  the  relief  of  inflammation,  yet  to  arrest  the  progress  of  the 
disease,  means  must  be  had  recourse  to  calculated  to  promote 
the  neutralization  and  elimination  of  the  rheumatic  virus,  which 
is  at  once  the  source  and  maintenance  of  the  disease.  And 
experience  has  proved  what  theory  most  justly  leads  us  to  an- 
ticipate, namely,  that  blisters  and  derivatives  are  more  efficient 
than  general  venesection,  and  that,  although  local  depletion 
and  full  mercurial  action  may  be  needed  for  the  relief  of  ex- 
cessive local  action,  yet  that  no  cure  can  be  efiected  without 
due  regard  to  the  neutralization  of  the  poison,  and  the  promo- 
tion of  the  various  excretions  by  which  its  elimination  is  brought 
about.  Alkalies  in  full  doses  with  opium  and  diuretics  are  as 
useful  here  as  in  cure  of  the  articular  symptoms,  and  active 
purging  by  the  neutral  salts  is  also  of  essential  service.  But 
while  employing  blisters  and  the  other  remedies  mentioned,  the 
serious  nature  of  the  local  mischief  must  not  be  lost  sight  of 
for  a  moment,  and  according  as  the-  symptoms  are  indicative  of 
pneumonia,  or  of  pleuritic  inflammation,  so  must  antimony  or 
calomel  be  administered. 

In  rheumatic  pleurisy,  however,  as  in  rheumatic  pericarditis, 
it  is  necessary  to  observe  the  greatest  circumspection  in  the 
employment  of  lowering  treatment;  the  patients  are  often  pale 
and  exsanguine,  and  their  strength  is  taxed  to  the  utmost,  not 
only  by  the  long  duration  of  the  disease,  but  by  the  want  of 
sleep  and  excessive  perspiration  which  usually  attend  it.     And 


286  INFLAMMATION    OF    THE    LUNGS    AND    PLEURiE 

if  under  these  circumstances  unnecessary  depression  be  induced 
by  over  activity  in  the  treatment,  a  healthy  lymph-eifusing  in- 
flammation may  take  on  an  unhealthy  pus-generating  char- 
acter. 

The  following  cases  may  serve  to  illustrate  the  violence  of, 
and  extreme  danger  attendant  upon,  inflammation  of  the  pul- 
monary structures  when  occurring  in  the  course  of  acute  rheu- 
matism : 

Fred.  Ford,  aged  32,  came  under  my  care  at  St.  George's 
Hospital,  on  the  16th  of  November,  1850,  sufi"ering  from  acute 
rheumatism  of  four  days'  duration,  principally  afi"ecting  the 
right  hand  and  elbows,  which  were  red,  tumefied,  and  extremely 
painful.  He  appeared  to  have  been  going  on  well  until  the 
morning  of  the  19th,  when  he  began  to  complain  of  catching 
pain  on  the  left  side  of  the  chest,  his  pulse  became  sharp,  and 
his  countenance  expressive  of  anxiety.  Auscultation  revealed 
a  loud  systolic  mitral  murmur,  as  also  pleuritic  friction  and 
aegophony  at  the  seat  of  pain.  He  was  a  thin  and  sickly  per- 
son, a  working  tailor  by  trade,  and  three  times  a  day  had  been 
taking,  by  my  orders,  a  niter  draught,  w'ith  fifteen  minims  of 
colchicum  wine,  ten  drops  of  laudanum,  and  a  drachm  of  potas- 
sio-tartrate  of  soda.  Directly  he  began  to  exhibit  symptoms 
of  pulmonary  and  cardiac  inflammation,  twelve  leeches  w'ere 
applied  to  the  seat  of  pain,  and  their  application  was  followed 
by  a  blister;  and  to  the  draught  were  added  twenty  minims  of 
antimonial  wine,  and  a  drachm  of  tartarized  soda;  at  the  same 
time,  a  pill  was  ordered  to  be  taken  every  six  hours,  containing 
three  grains  of  calomel  and  one  of  opium.  The  leeches-bites 
bled  freely,  the  blister  did  its  duty  well,  and  within  three  days 
he  was  brought  under  the  influence  of  mercury;  nevertheless, 
the  inflammation  continued,  modified  perhaps  in  its  course, 
until  the  Avhole  of  the  left  side  of  the  chest  was  dull  on  percus- 
sion, and  aegophony  was  audible  only  in  the  supra-scapular 
region.  Nor  did  the  pleuritic  inflammation  alone  proceed  un- 
checked. Rusty-colored  pneumonic  expectoration  bore  witness 
to  the  existence  of  mischief  in  the  lungs,  and  the  stethoscope 
revealed  fine  crepitation  passing  gradually  over   the   inferior 


AS   A    CONSEQUENCE    OF   ACUTE    RHEUMATISM.  287 

third  of  the  right  lung.  Five  days  more  passed  away,  during 
which  a  blister  was  again  applied,  and  yet  there  was  no  material 
amendment  in  the  symptoms.  I  now  became  seriously  alarmed 
for  his  safety,  for  the  breathing  was  hurried  and  oppressed,  his 
countenance  anxious,  and  the  pulse  small  and  faltering.  The 
next  day,  however,  ushered  in  a  brighter  epoch  in  the  history 
of  his  attack.  The  rheumatic  symptoms  were  rapidly  subsiding, 
and  with  their  cessation  the  more  urgent  chest  symptoms  began 
to  disappear :  the  breathing  gradually  became  less  embarrassed, 
and  the  case  proceeded  favorably  to  its  termination.  Blisters 
were  repeatedly  applied  to  the  chest,  diuretics  were  given  freely, 
and  on  the  23d  of  January,  1851,  the  breathing  was  fairly  re- 
established throughout  the  chest,  and  my  patient  had  got  rid 
of  his  present  distress,  at  the  expense  of  a  damaged  mitral 
valve,  and  an  universally  (?)  adherent  pleura. 

Cases,  hoAvever,  not  unfrequently  occur,  in  which,  either  from 
the  extent  and  intensity  of  the  pulmonary  inflammation,  from 
the  fearful  mischief  in  other  organs  Avhich  accompanies  it, 
or  from  the  depressed  condition  or  unhealthy  constitution  of 
the  patient,  a  fatal  issue  is  almost  inevitable.  Dr.  Latham 
has  put  several  fatal  cases  on  record;  and,  among  the  sixteen 
fatal  cases  of  which  I  have  given  abstracts  in  a  previous  chapter, 
no  fewer  than  nine  were  accompanied  by  extensive  and  acute 
pulmonary  inflammation.^  A  case  of  this  sort  was  admitted 
into  St.  George's  Hospital  on  the  4th  of  March,  1839,  under 
the  care  of  my  colleague.  Dr.  Wilson.  The  patient,  a  servant- 
maid,  aged  32,  by  her  own  account,  had  been  ill  for  three  weeks 

1  See  Cap.  VIII,  of  tliis  Treatise.  Subjoined  is  an  account  of  tlie  pulmonary 
inflammation  in  the  several  cases. 

Case     I.  Pneumonia  on  both  sides  of  the  chest,  going  on  to  partial  hepati- 
zation of  the  lungs. 
"        II.  Pneumonia  affecting  both  lungs,  and  double  pleurisy. 
"      III.  Pleurisy  on  both  sides  of  the  chest. 
"       V.  Pleurisy  on  both  sides  of  the  chest. 
"    VII.  Pleurisy  on  both  sides  of  the  chest. 

"      IX.  Pneumonia  on  both  sides,  pleurisy  on  one  side  of  the  chest. 
"       X.  Bronchitis  affecting  both  lungs. 
"    XII.  Single  pleuris3^  ^ 

"    XV.  Pneumonia  of  l)oth   lungs  going   on   to   the   production  of  gray 
hepatization.     Single  pleurisy. 


288  INFLAMMATION    OF    THE    LUNGS    AND    PLEURAE 

before  lier  admission  into  the  hospital.  She  was  attacked 
during  the  catamenial  period  by  pains  all  over  her,  and  shiver- 
ings,  with  occasional  heats  and  sweatings.  She  was  also  sick. 
The  pain  then  "fell  on  her  chest,"  with  much  cough  and  thick 
expectoration.  A  week  afterward  her  wrists  and  knees  became 
swollen  and  red.  When  removed  into  the  hospital,  the  joints 
were  no  longer  swollen,  but  she  complained  of  excessive  pain 
beneath  the  sternum,  increased  on  inspiration.  "On  the  6th 
of  March  she  was  attacked  bj  a  severe  rigor,  the  first  of  a 
long  series  of  shivering  fits,  which  afterward  gave  place  to 
periodical  attacks  of  dyspnoea,  in  one  of  which  the  patient 
expired  on  the  26th."  The  body  was  examined  on  the  27th, 
twenty-six  hours  after  death.  There  was  considerable  effusion 
into  all  the  serous  cavities  of  the  chest:  "the  pericardium  con- 
tained about  eight  ounces  of  fluid  slightly  flaked  by  lymph :  a 
little  of  the  soft  yellow  deposit  rested  on  the  heart:  the  left 
auricle  Avas  greatly  distended  by  a  tolerably  firm  coagulum: 
its  valvular  surface  was  beset  by  numerous  warty  vegetations, 
and  the  edges  of  the  valve  were  much  thickened  and  contracted. 
From  the  regurgitation  thus  effected  by  a  dam  in  the  blood's 
current,  partial  hemorrhage  had  followed  in  the  lungs,  which 
exhibited  many  instances  of  the  circumscribed  apoplectic  clot. 
One  entire  lobe  was  in  this  way  closed  against  air.  It  was  of 
peculiar  interest  in  this  case,  that  the  warty  vegetations  were 
likewise  indigenous  to  the  right  side  of  the  heart.  They  were 
observed  in  great  numbers  on  the  auricular  surface  of  the  tri- 
cuspid valve,  some  of  them  even  projecting  round  into  the 
cavity  of  the  ventricle.  The  other  viscera  were  generally 
healthy."^ 

Another  case,  in  which  the  pulmonary  symptoms  assumed 
an  equally  grave  aspect,  fell  under  my  observation  in  St. 
George's  Hospital  in  the  year  1845.  Frances  Webster,  aged 
18,  a  thin  delicate  girl,  Avhose  father  was  a  martyr  to  rheu- 
matism, Avas  admitted  into  the  hospital  on  the  J4th  of  March, 
under  the  care  of  Dr.  Wilson.  At  the  age  of  15,  while  recov- 
ering from  scarlatina,  she  had  been  attacked  by  acute  rheu- 

1  See  the  Report,  hy  Dr.  Wilson,  in  the  "Lancet"  for  November  16,  1844. 


AS    A    CONSEQUENCE    OF   ACUTE    RHEUMATISM.  289 

matism,  and  had  ever  since  been  subject,  at  short  intervals,  to 
wandering  pains  in  the  limbs,  unattended,  however,  by  redness 
or  swelling.  Eight  days  before  her  removal  to  the  hospital, 
she  had  experienced  rigors,  followed  by  dyspnoea,  palpitation, 
and  catching  pain  in  the  cardiac  region ;  and  on  the  day  before 
admission  had  begun  to  manifest  external  symptoms  of  rheu- 
matism, Avhich  showed  themselves  by  inflammation  of  several 
of  the  larger  joints.^  On  admission,  coincidently  with  redness 
and  swelling  of  the  joints,  there  existed  endocardial  and  exo- 
cardial  inflammation.  There' was  extreme  irregularity  of  the 
pulse,  Avith  extended  dullness  on  percussion  in  the  prrecordial 
region.  The  heart's  sounds  were  distant  and  muflfled,  and  at 
the  base  of  the  heart  were  both  obscured  by  a  loud  to-and-fro 
sound  of  friction.  At  the  apex,  however,  a  loud  systolic  bel- 
lows murmur  was  distinctly  audible.  Small  bleedings  were 
resorted  to,  a  blister  was  applied  to  the  chest,  and  saline  medi- 
cines, with  antimony,  were  administered,  while  the  system  was 
being  brought  under  the  influence  of  mercury.  By  degrees 
the  physical  signs  gave  evidence  of  the  salutary  eff'ect  of  the 
treatment  employed,  for  the  heart's  sounds  became  clearer  and 
less  distant,  the  dullness  in  the  praecordial  region  less  extended, 
and  the  pulse  steadier.  At  the  same  time  the  articular  swell- 
ings subsided,  and  everything  seemed  to  promise  a  favorable 
issue.  But  on  the  twelfth  day  after  admission,  the  articular 
inflammation  recommenced,  and  with  it  a  catching  pain  on  the 
right  side  of  the  chest,  accompanied  by  pleuritic  friction  and 
ajgophony,  announcing  the  supervention  of  acute  pleurisy. 
Subsequently,  an  attack  of  a  similar  nature  commenced  on 
the  left  side  of  the  chest,  and  with  it  inflammation  of  the  lung 
itself.  The  poor  girl's  breathing  was  now  exceedingly  op- 
pressed, her  powers  of  life  were  manifestly  failing,  and  her 
back  began  to  slough.  Still,  however,  she  lingered  on,  and 
even  survived  an  attack  of  peritonitis  which  supervened  a  few 

^  "Sometimes,"  says  Dr.  Williams,  ("On  Morbid  Poisons,"  p.  10,)  "when  a 
poison  acts  on  many  membranes,  the  usual  order  of  attack  is  inverted."  Such 
appears  to  have  been  the  case  in  the  present  instance,  for  the  heart  was  evi- 
dently attacked  some  days  before  the  invasion  of  the  joints. 


290  DISORGANIZATION    OF   THE   JOINTS 

days  afterward.  But  on  the  2Tth  of  April  a  fresh  attack  of 
inflammation  was  set  up  on  the  left  side,  and  she  sank  on  the 
28th,  under  the  combined  influence  of  her  several  maladies. 

A  post-mortem  examination  revealed,  as  was  expected,  a 
heart  not  greatly  enlarged,  but  presenting  a  pericardium  almost 
universally  adherent,  by  means  of  recently  eff"used  lymph ;  a 
mitral  valve  fringed  with  beads  and  festoons  of  recent  lymph 
and  fibrin  ;  a  copious  eff'usion  of  lymph  and  serum  into  the 
pleural  cavity  on  either  side  ;  the  left  lung  passing  into  a  state 
of  red  hepatization  ;  and  bands  of  recent  lymph,  together  with 
turbid  serum,  the  ordinary  products  of  recent  peritonitis,  in  the 
cavity  of  the  abdomen.^ 

How  full  of  painful  interest  are  such  cases  !  how  pregnant 
with  hints  for  our  guidance  and  instruction  !  ^o  particular 
organ  or  set  of  organs  was  alone  the  seat  of  morbid  action. 
The  heart  on  its  external  and  internal  surface,  the  pleura  on 
either  side  of  the  chest,  the  lungs  and  the  lining  membrane  of 
the  abdomen,  the  synovial  membrane  of  the  joints,  the  liga- 
ments and  the  parts  external  to  the  joints,  at  once  the  seat  of 
active  inflammation  !  How  widely  spread  must  be  the  cause  of 
such  extended  mischief!  how  unlike  the  eff'ects  of  any  local 
agency  !  No  impartial  inquirer  can  fail  to  admit  the  import- 
ance of  such  cases,  no  zealous  physiologist  to  recognize  and 
appreciate  their  intimate  bearing  on  the  true  pathology  of  the 
disease. 

One  other  complication  of  acute  rheumatism  is  deserving  of 
especial  notice ;  I  refer  to  disorganization  of  the  joints,  which 
sometimes  ensues  when  the  articular  inflammation  is  stationary 
for  any  length  of  time.  Generally  speaking,  the  liability  to 
this  occurrence  varies  in  inverse  proportion  to  the  number  of 
articulations  affected,  but  there  is  always  just  ground  for 
anxiety,  respecting  the  integrity  of  a  joint,  which,  in  spite  of 
treatment,  remains  swollen  and  painful  unusually  long.  I  have 
seen  so  many  cases  of  unequivocal  rheumatism  giving  rise  to 

1  For  further  particulars  respecting  the  autopsy  of  this  case,  see  the  '•  Ab- 
stract," at  p.  191,  of  this  Treatise,  as  also  the  '^  rost-mortcm  Book' for  1845, 
preserved  in  the  Museum  of  St.  George's  Hospital. 


AS    A    CONSEQUENCE    OF    ACUTE    RHEUMATISM.  291 

acute  lymph-effusing  inflammation  of  the  joints,  and,  in  some 
few  instances,  to  suppuration,  that  I  am  convinced  of  the  neces- 
sity for  the  greatest  vigilance  in  watching  the  progress  of  the 
articular  inflammation,  and  taking  every  precaution  for  its 
speedy  subjugation.  When  pain  and  swelling  become  fixed  in 
any  particular  joint,  and  continue  there  after  the  symptoms  in 
the  other  joints  have  subsided,  there  is  always  reason  to  fear 
that  inflammation  has  taken  a  deeper  hold  than  usual  of  the 
articular  structures,  has  produced  there  some  of  its  ordinary 
ill  effects,  and  if  not  arrested-  will  go  on  to  ulceration  of  the 
cartilages,  and  the  production  of  a  stiff  joint. 

The  necessity  for  strict  attention  to  the  progress  of  the 
articular  symptoms  of  rheumatism  cannot  be  enforced  better 
than  by  citing  the  particulars  of  one  or  two  cases  in  which, 
during  life,  there  has  been  every  token  of  threatening  articular 
disorganization,  or  every  evidence  after  death  of  extensive 
local  mischief. 

Ann  Stevens,  a  thin  delicate-looking  girl,  aged  18,  became 
a  patient  under  my  care,  at  St.  George's  Hospital,  on  the  14th 
of  September,  1850.  She  had  been  suffering  nearly  two  weeks 
from  acute  rheumatism,  principally  affecting  the  right  hand  and 
wrist,  which  were  swollen  and  inflamed.  Other  parts  had  been 
temporarily  affected,  but  the  right  wrist  had  remained  swollen 
throughout.  A  week  passed  away,  and,  though  all  pain  had 
ceased  in  other  parts  of  the  body,  yet,  in  spite  of  fomentations, 
her  wrist  remained  as  much  inflamed  as  ever,  and  the  pain  was 
aggravated  by  the  slightest  motion.  Still  I  hoped  to  conquer 
the  disease  by  the  agency  of  medicine  addressed  to  the  relief  of 
rheumatism,  but  as,  at  the  end  of  a  fortnight,  she  had  shown 
no  signs  of  amendment,  and  mischief  appeared  imminent,  I 
judged  it  expedient  to  put  some  leeches  on  the  joint,  and  to 
folloAV  their  application  by  a  blister,  giving  her  at  the  same  time 
calomel  and  opium.  This  at  once  alleviated  her  suffering  ;  the 
tension  of  the  inflamed  part  was  relieved,  the  redness  subsided, 
and,  in  the  course  of  another  week,  the  pain  and  the  swelling 
had  been  greatly  subdued.  Some  pain,  however,  still  continued, 
so  another  blister  was  applied,  and,  subsequently,  in  order  to 


292  DISORGANIZATION    OF   THE    JOINTS 

insure  perfect  rest,  her  arm  was  placed  on  a  splint,  and  the 
wrist  was  blistered  as  before.  This  completed  what  the  first 
local  applications  had  eflfectuallj  begun  ;  the  pain  subsided, 
and  there  remained  only  thickening  of  the  parts  about  the 
joint,  and  some  effusion,  probably  of  thickened  synovial  fluid, 
within  the  capsules.  This  was,  after  a  time,  removed  by 
absorption,  under  the  influence  of  the  compound  Iodine  lotion, 
and  she  was  discharged  on  the  IGth  of  November,  very  little 
stifi'ness  of  the  joints  remaining. 

So  also,  in  the  case  of  Ann  Conolly,  aged  17,  who  was  ad- 
mitted into  St.  George's  Hospital,  on  the  25th  of  August,  1847, 
under  the  care  of  my  colleague.  Dr.  Nairne.  She  had  been 
suffering  one  week  from  acute  rheumatism,  principally  affecting 
the  hands  and  wrists,  and  at  the  time  of  her  admission,  the 
wrist,  and  several  of  the  smaller  joints  of  the  hands,  were 
inflamed  and  swollen.  She  was  greatly  out  of  health,  but  under 
the  use  of  purgatives,  salines,  and  the  mistura  guaiaci  of  the 
Pharmacopoeia,  the  pains  and  swellings  had  all  subsided  by  the 
3d  of  September,  except  those  in  the  third  finger  of  the  left 
hand,  and  the  thumb  of  the  right  hand.  In  those  parts  the 
inflammation  continued  unabated,  and  so  obstinate  did  it  prove, 
and  so  severe  in  its  nature,  that  crepitation  could  at  last  be  felt 
distinctly  in  the  aff"ected  joints.  In  spite  of  blisters  and  mus- 
tard poultices,  which  were  repeatedly  applied,  of  colchicum, 
which  was  administered  internally,  and  of  full  mercurial  action, 
which  was  twice  induced  before  the  symptoms  were  entirely 
subdued,  the  poor  girl  was  not  in  a  state  to  leave  the  Hospital 
until  the  3d  of  November,  when  she  had  very  little  motion  in  the 
thumb,  and  her  finger  was  anchylosed  in  a  hent  jjosition. 

Some  cases,  however,  do  not  issue  so  favorably;  the  patient 
sinks  either  from  the  irritation  of  the  articular  inflammation, 
or  from  the  concurrence  of  some  serious  internal  complication. 
In  such  cases  there  has  been  found  every  stage  of  acute  artic- 
ular inflammation,  from  simple  congestion  to  extreme  capillary 
injection  of  the  aff"ected  parts,  with  effusion  of  lymph  and  pus. 
In  the  case  of  the  young  girl  already  referred  to  (p.  275)  as 
having  been  complicated  by  active  delirium,  "  each  knee-joint 


I 


AS    A    CONSEQUENCE    OF    ACUTE    RHEUMATISM.  293 

contained  rather  more  than  a  drachm  of  turbid,  glutinous  serum, 
which  was  alkaline,  highly  albuminous,  containing  many  oil- 
globules  and  cells  the  size  of  pus-globules,  having  well-marked 
nuclei,  and  of  a  specific  gravity  greater  than  the  albuminous 
liquid.  Some  cells  were  also  seen  three  times  as  large  as  those 
containing  granular  matter  and  nuclei. 

"  In  the  upper  part  of  the  cavity  of  each  joint,  a  tliickhli 
mass  of  fibrin  an  hicli  and  a  half  broad,  and  about  the  same 
length,  tvas  lying.  One  of  these  masses  was  deeply  stained 
with  red  blood,  but  no  vessels  could  be  traced  in  it.  On 
removing  these  substances  the  synovial  membrane  at  the  iipper 
jjart  of  each  joint  was  seen  to  be  intensely  red,  and  highly  vas- 
cular, and  to  present  the  most  striking  contrast  to  the  white, 
shining  cartilage  in  which  no  vessels  could  be  traced,  and 
which  was  not  altered  in  appearance. 

"  One  elbow-joint  was  opened,  and  it  contained  a  clear,  glu- 
tinous, synovial  fluid,  apparently  without  any  cells  in  it."^ 

In  some  instances  inflammation  has  produced  even  more 
disastrous  consequences,  having  gone  on  rapidly  to  suppuration 
and  complete  disorganization  of  the  joint.  A  case  in  which 
ulceration  of  the  cartilages  took  place,  has  been  recorded  by 
my  colleague,  Mr.  Caesar  Hawkins,  in  the  "  Lancet"  for  August 
23d,  1851  ;  and  others  are  to  be  found  in  the  various  medical 
journals.  Within  my  own  observation,  five  instances  have 
occurred,  of  three  of  which  an  abstract  has  been  already  given. ^ 
The  post-mortem  appearances  observed  in  Case  IV  may  be 
taken  as  a  sample.  In  that  case  "  the  right  knee  and  the  left 
wrist-joints  were  still  swollen,  and  when  cut  into,  were  found 
to  contain  large  quantities  of  thick,  viscid  fluid,  mixed  with 
lymph  and  pus.  The  sheaths  of  the  tendons  at  the  back  of 
both  wrist-joints  contained  a  quantity  of  thick  puriform  fluid. 

1  St.  George's  Hospital  Posl-morleni  Book  for  1850,  preserved  in  the  Museum 
of  the  Hospital. 

2  See  Abstract  of  Cases  IV,VII,  and  XVI,  recorded  in  Cap.  VII.  In  Case  XIII 
a  large  number  of  pus-globules  were  discovered  by  the  microscope,  but  as  t!ie 
fluid  contained  in  the  joints  appeared  to  be  thickened  synovia,  containing  pus- 
globules,  rather  tlian  a  purely  purident  or  sero-purulcnt  fluid,  it  is  probable 
that  suppuration  was  only  just  commencing  at  the  time  of  the  patient's  death 


294 


DISORGANIZATION    OF    THE    JOINTS,    ETC. 


The  left  knee-joint  contained  a  larger  quantity  of  synovia  than 
natural,  and  the  synovial  membrane  of  this  joint  was  slightly 
increased  in  vascularity."' 

As  then  very  serious  lesions  may  arise  from  rheumatic  artic- 
ular inflammation,  even  when  the  greatest  caution  is  observed, 
and,  as  such  lesions  are  more  likely  to  occur  when  the  local 
symptoms  are  neglected,  it  behooves  us  to  do  all  in  our  power 
for  their  relief,  and  to  watch  carefully  for  the  earliest  indica- 
tions of  commencing  mischief.  From  the  first,  as  already 
stated,  much  comfort  may  be  afforded  by  the  application  of 
warm  or  tepid  fomentations,  and  repeated  experiments  have 
convinced  me  that  none  prove  so  efficient  as  the  alkaline  and 
sedative  solution,  of  which  I  have  elsewhere  given  the  formula. - 
When  this  is  fairly  and  fully  employed  from  the  first,  artic- 
ular mischief  will  rarely  if  ever  happen.  But  in  such  matters 
it  is  not  prudent  to  run  the  slightest  risk,  and  when  inflamma- 
tion attaches  itself  with  more  than  usual  obstinacy  to  any  par- 
ticular joint,  leeches  or  a  blister  should  be  applied  at  once,  and 
repeated,  if  necessary,  while  the  system  is  being  brought  under 
the  influence  of  mercury.  By  these  means,  and  by  perfect 
rest,  which  is  best  insured  by  means  of  a  splint,  the  pain  will 
be  subdued,  the  swelling  got  rid  of,  and  the  integrity  of  the 
patient's  joints  preserved. 


} 


1  For  a  detailed  account  of  this  case,  with  the  dissection  after  death,  see  St. 
George's  Hospital  Post-viortem  Book  for  1845,  p.  218. 

2  Page  119. 


CHAPTER  XI. 

ON  RHEUMATIC  GOUT. 

Closely  allied  to  rheumatism,  yet  presenting  some  of  the 
features  of  gout,  is  that  obstinate,  painful,  and  distressing  mal- 
ady, which  is  known  under'  the  title  of  Rheumatic  Gout.^ 
Whether  viewed  in  relation  to  the  amount  of  present  suffering 
it  inflicts,  or  to  the  permanent  injury  and  distortion  it  entails, 
it  ranks  among  the  most  formidable  of  this  class  of  disorders, 

1  This  form  of  disease  has  been  described  by  Dr.  Macleod  under  the  title  of 
■•  Capsular  Rheumatism  ;"  bj  Dr.  Todd  under  that  of  "  Chronic  Rheumatism  of 
the  Joints  ;"  and  by  Dr.  Adams,  of  Dublin,  under  that  of  ''  Chronic  Rheumatic 
Arthritis."  These  appellations,  however,  appear  to  me  objectionable,  inasmuch 
as  they  refer  the  local  changes  to  rheumatism,  with  which  they  have  no  sort 
of  connection.  Dr.  Garrod  objects  to  the  title  of  Rheumatic  Gout,  and  pro- 
poses the  term  "  Rheumatoid  Arthritis."  He  states  that  we  should  be  equally 
justified  in  calling  certain  cases  of  scarlatina,  or  measles,  by  the  compound 
title  of  "  Rubeolo-Scarlatina,"  as  in  applying  the  term  Rheumatic  Gout  to  the 
disease  under  consideration.  But  this  is  simply  an  incorrect  view.  Rheu- 
matic Gout  is  not  a  mere  variety  of  Gout  or  of  Rheumatism,  nor  is  it  a  com- 
pound of  the  two  diseases  ;  it  is  essentially  distinct  from  them  both,  has  a 
special  pathology  of  its  own,  and  requires  a  distinctive  title.  The  term  Rubeolo- 
Scarlatina  could  only  be  applied  legitimately  to  a  disease  bearing  a  strong 
resemblance  to  Rubeolo  and  Scarlatina,  yet  having  a  separate  and  independent 
existence.  To  such  a  disorder  its  application  would  be  appropriate.  On  the 
other  hand,  if  the  term  Rheumatoid  Arthritis  were  to  be  employed,  a  due  regard 
to  our  nomenclature  would  necessitate  the  disuse  of  the  terms  Gout  and 
Rheumatism,  and  the  substitution  of  the  titles  "  Gouty  Arthritis'"  and  "  Rheu- 
matic Arthritis." 

My  own  opinion  in  favor  of  the  term  "  Rheumatic  Gout"  remains  unshaken. 
The  titles  of  diseases  are  seldom  used  to  indicate  their  pathology,  but  rather 
as  a  means  of  establishing  their  identity.  In  this  point  of  view,  the  terra 
Rheumatic  Gout  is  unexceptionable.  It  points  to  the  class  of  diseases  with 
which  the  malady  in  question  is  closely  allied,  yet  at  the  same  time  it  is  suffi- 
ciently distinctive,  and  cannot  be  confounded  with  either  Gout  or  Rheumatism. 
Further,  it  has  the  great  advantage  of  being  already  recognized,  and  extensively 
used.  Even  Dr.  Garrod  has  deserted  his  favorite  bantling,  "  Rheumatoid  Arth- 
ritis," and  has  adopted  the  term  "  Rheumatic  Gout"  as  the  title  of  his  l)Ook. 

In  truth,  it  is  a  most  appropriate  title ;  and  it  is  to  be  hoped  the  Profession 
"will  concur  in  limiting  its  application  to  the  disease  under  consideration. 


296  RHEUMATIC    GOUT. 

Its  symptoms  are  not  only  temporarih'^  severe,  but  often  lead 
to  irremediable  helplessness. 

The  natural  history  of  rheumatic  gout  accords  but  little  with 
that  of  true  rheumatism,  and  is  equally  inconsistent  with  that 
of  true  gout.  It  differs  from  rheumatism  in  the  frequency  of 
its  attacks,  and  the  increase  exhibited  at  each  recurrence  in 
the  severity  and  obstinacy  of  its  symptoms ;  in  invading  the 
small  joints  in  preference  to  the  large;  in  being  more  stationary, 
and  usually  causing  thickening  and  permanent  enlargement ; 
in  never  involving  the  heart  or  its  membranes ;  and  in  some- 
times producing  desquamation  of  th§  skin.  In  all  these  par- 
ticulars it  strikingl}'^  exhibits  a  gouty  nature.  But  it  is  unlike 
gout,  in  numbering  among  its  victims  the  young,  the  middle- 
aged,  the  slender,  and  the  weakly ;  in  attacking  women  more 
frequently  than  men ;  in  invading  several  joints  simultaneously  ; 
and  in  being  ordinarily  unattended  by  dyspeptic  symptoms. 
In  all  these  points  its  rheumatic  nature  is  strongly  marked.  It 
maintains,  indeed,  as  its  name  implies,  a  place  intermediate  be- 
tween the  two  disorders ;  it  is  identical  with  neither,  yet  presents 
some  characteristics  of  both,  and  is,  therefore,  well  described 
by  the  popular,  yet  distinctive  title  of  rheumatic  gout.^ 

In  its  acute,  and  apparently  most  terrible  form,  this  disease 
may  be  confounded  with  acute  rheumatism ;  but  when  carefully 
examined,  its  history,  symptoms,  progress,  and  terminations, 
all  serve  to  illustrate  its  distinctive  character.  Referable, 
without  doubt,  to  some  constitutional  peculiarity  closely  con- 
nected with  perverted  assimilation,  it  selects  as  its  victims 
either  the  weakly  and  unhealthy,  in  whom  the  natural  excre- 
tions are  imperfect  or  deficient,  or  else  fixes  upon  those  who, 
though  usually  robust,  have  been  subjected  to  some  cause  of 
mental  or  bodily  depression.     It  is  remarkably  prone  to  aflfect 

'  I  shall  presentlj-  give  the  reasons  which  have  led  rae  to  believe  that  it  is 
essentially  distinct  from  true  rheumatism,  and  equally  so  from  true  gout;  that 
it  has  a  special  pathology,  and  demands  a  peculiar  method  of  treatment  j  and 
that,  if  regarded  and  treated  as  either  rheumatism  or  gout,  it  will  usually  run 
on  unchecked  in  its  course. 


RHEUMATIC    GOUT.  297 

the  children  of  consumptive  parents  ;^  it  attacks  the  offspring 
of  gouty  or  rheumatic  persons  whose  health  is  impaired,  and 
whose  nervous  energy  is  exhausted  by  the  labor  and  anxieties 
of  business  ;  it  fixes  upon  the  girl  just  arriving  at  puberty,  in 
whom  the  uterine  functions  are  ill  performed ;  it  invades  the 
stiffening  articulations  of  the  woman  who  has  arrived  at  that 
time  of  life  which  is  marked  by  the  cessation  of  the  monthly 
periods ;  it  shows  itself  during  the  state  of  debility  which  fol- 
lows a  miscarriage,  or  a  difficult  and  protracted  labor,  more 
especially  when  the  labor  has-  been  accompanied  by  flooding  ; 
it  is  a  frequent  attendant  upon  renal  disease;  upon  the  cachexia 
produced  by  syphilis  or  gonorrhoea,  or  neglected  mercurial 
action  ;  and  it  is  a  common  sequel  of  over-long  suckling,  of 
excessive  venery,  of  severe  and  long-continued  mental  exercise, 
and  of  mental  distress  and  bodily  exhaustion.  Neither  ao-e 
nor  sex  affords  immunity  from  its  invasion;  but  most  commonly 
it  shows  itself  from  the  age  of  thirty-five  onward ;  and  its  ear- 
liest attacks  are  usually  seen  in  girls  whose  uterine  functions 
are  suspended  or  ill  performed.^ 

Its  attack,  when  acute,  may  be  ushered  in  by  considerable 
fever,  together  with  pain  and  aching  of  the  joints,  and  after  a 


'  Of  119  patients  of  whom  I  have  raade  special  inquiry  on  this  subject,  no 
less  than  23,  or  1  in  every  5-2,  had  lost  a  parent,  or  one  or  more  brothers  or 
sisters  by  consumption. 

2  In  almost  every  instance  which  has  fallen  under  my  notice  of  its  occurrence 
in  very  early  life,  it  has  been  either  hereditary  or  else  connected  with  disor- 
dered uterine  function.  Within  th  ;  last  four  years  I  have  had  under  my  care 
no  less  than  eleven  girls,  under  eighteen  years  of  age,  suffering  from  this  com- 
plaint. In  every  instance,  save  one,  the  monthly  periods  were  disordered,  fa 
the  years  1851-2  I  had  two  girls  under  my  care,  at  St.  George'.<(  Hospital,  of 
the  respective  ages  of  fifteen  and  seventeen,  whose  joints  were  frighLfully  dis- 
torted by  the  disease.  In  the  former  the  menses  had  first  appeared  at  the  age 
of  thirteen,  but  had  only  reappeared  three  times  since;  in  the  latter  they  had 
been  absent  a  year  and  a  half,  and  their  cessation  was  coincident  with  the 
commencement  of  ill  health.  The  first  of  these  patients,  at  my  earnest  desire, 
went,  for  four  months,  to  Bath,  and  returned  much  benefited  by  her  re.-idence 
there.  Dr.  Haygarth's  experience  also  led  him  to  connect  its  appearance  ia 
women  with  irregularity  of  the  catamenia,  for  he  remarks,  (''  Clinical  .Medicine  " 
p.  18.3,)  that  "out  of  thirty-three  women  in  whom  he  observed  it,  three  only 
were  afHicted  with  it  during  the  period  of  regular  menstruation,  and  of  these 
one  had  suffered  twelve  abortions." 
20 


298  RHEUMATIC    GOUT. 

time,  some  redness  may  supervene,  just  as  in  a  paroxysm  of 
ordinary  rheumatism.  But  more  generally  there  is  little  ex- 
ternal discoloration,  and  far  less  heat  of  skin,  less  furring  of 
the  tongue,  less  bounding  of  the  pulse,  in  short,  less  active 
febrile  disturbance,  than  in  acute  rheumatism ;  and  though  the 
skin  may  be  moist,  and  the  urine  loaded  with  lithates,  yet  the 
urine  is  less  loaded  than  in  a  corresponding  state  of  excitement 
from  true  rheumatism,  and  the  perspiration  is  less  constant, 
less  sour-smelling,  and  less  profuse.  But  the  liver  usually  acts 
more  imperfectly  than  in  genuine  rheumatism,  as  is  evidenced 
by  the  yellowness  of  the  complexion  and  the  conjunctivae,  the 
yellowness  of  the  fur  on  the  tongue,  and  the  paleness  of  the 
alvine  evacuations. 

The  form  and  the  situation  of  the  articular  swellings  present 
well-marked  peculiarities.  Whereas  the  larger  joints  most 
commonly  suffer  in  true  rheumatism,  the  small  joints  of  the 
hands  are  the  parts  most  frequently  affected  in  this  disease ; 
and  when  the  knees,  or  other  of  the  larger  articulations  are 
attacked,  the  character  of  the  swelling  is  peculiar  and  diag- 
nostic. It  is  more  circumscribed  than  the  articular  swelling  of 
acute  rheumatism,  and  in  its  form  and  character  indicates  the 
existence  of  effusion  within  the  joint  and  the  adjacent  bursas 
and  tendons,  rather  than  into  the  surrounding  structures.  In 
the  knee-joint  this  peculiarity  is  strikingly  manifest.  While 
there  is  little  if  any  effusion  into  the  surrounding  tissues,  the 
synovial  membrane,  full  and  distended,  may  be  seen  projecting 
at  those  parts  where  the  adjacent  structures  offer  least  resist- 
ance, and  if  the  two  hands  be  placed  one  on  either  side  of  the 
joint,  fluctuation  may  be  made  perceptible  to  the  touch.  The 
adjoining  bursae,  and  the  sheaths  of  the  tendons,  are  also  felt 
as  circumscribed  swellings.  Another  peculiarity  is,  that  the 
local  symptoms  are  less  migratory  and  more  obstinate  in  their 
continuance,  so  that  there  is  greater  danger  of  disorganization 
of  the  joints,  or  of  thickening  in  their  immediate  vicinity. 
Indeed,  although  the  first  activity  of  the  articular  inflammation 
may  be  subdued  by  treatment  more  rapidly  than  under  corre- 
sponding circumstances  in  acute  rheumatism,  yet,  in  a  subacute 


RHEUMATIC   GOUT.  299 

or  chronic  form,  inflammatory  action  will  often  persist  for 
months,  producing  permanent  and  irreparable  mischief.  Nor 
are  the  differences  confined  to  the  points  already  specified ; 
they  are  strikingly  marked  in  the  nature  of  its  complications. 
It  is  unaccompanied  by  the  frightful  heart  disease  which  proves 
so  fatal  in  acute  rheumatism,  but  it  has  for  its  attendants  in- 
flammations of  the  eye,  the  pleurae,  and  the  brain. 

Sometimes,  however,  the  diagnosis  between  acute  rheuma- 
tism and  acute  rheumatic  gout  is  by  no  means  easy.  Indeed, 
I  entertain  considerable  doubt  whether  an  attack  which  com- 
mences as  acute  rheumatism,  may  not  change  its  type  under 
certain  conditions  of  treatment  or  constitution,  and  terminate 
eventually  in  rheumatic  gout.  Certain  it  is,  that  I  have  seen 
several  cases  characterized  at  first  by  all  the  most  striking 
features  of  acute  rheumatism,  by  the  thickly-coated  tongue, 
the  loaded  urine,  the  bounding  pulse,  the  profuse,  acid,  sour- 
smelling  perspirations,  and,  moreover,  by  the  peculiar  redness 
and  inflammation  shifting  rapidly  from  joint  to  joint,  and 
aff"ecting  the  larger  in  preference  to  the  smaller  joints,  in 
which,  after  the  first  intensity  of  the  attack  has  been  subdued, 
a  different  train  of  symptoms  has  arisen.  The  larger  joints 
have  gradually  obtained  immunity  from  pain,  but  the  small 
joints  of  the  hands  have  become  painful,  swollen,  and,  in  spite 
of  treatment,  permanently  enlarged ;  the  articular  inflamma- 
tion, though  less  urgent  in  its  character,  has  been  extremely 
obstinate  in  its  continuance,  and  has  lost  its  distinctive  migra- 
tory character  ;  the  skin  has  been  no  longer  bathed  in  prespira- 
tion ;  the  urine  no  longer  loaded ;  and  the  pulse  has  changed 
its  character,  and  from  being  full  and  bounding,  has  become 
soft  and  weak,  or  irritable.  Thus  I  have  repeatedly  known 
patients  crippled  by  unequivocal  rheumatic  gout,  which  com- 
menced, in  the  first  instance,  apparently  as  a  sequel  of  acute 
rheumatism.  In  two  instances  of  this  sort  the  patients,  after  a 
time,  came  again  under  my  notice,  suff"ering  from  well-marked 
rheumatic  gout,  which,  in  this  second  attack,  had  not  been 
preceded  by  symptoms  of  rheumatic  fever. 

When  the  disease  assumes  a  chronic  form,  it  admits  of  much 


300  RHEUMATIC    GOUT. 

more  readj  diagnosi?.  Occurring  sometimes  after  the  subsidence 
or  partial  disappearance  of  an  acute  paroxysm  of  the  disorder, 
but  more  commonly  without  any  previous  acute  attack,  it  may 
commence  without  any  remarkable  febrile  disturbance  while 
the  pulse  is  quiet,  the  tongue  almost  clean,  and  the  urine 
abundant,  pale  colored,  and  of  low  specific  gravity.  The 
patient's  chief  complaint  is  of  languor  and  loss  of  appetite, 
with  occasional  chilliness,  and  pain  and  stiffness  in  the  joints, 
which  soon  become  swollen  from  effusion  into  their  synovial 
cavities,  and  into  the  bursge  and  sheaths  of  tendons  immediately 
surrounding  them.  Sometimes,  indeed,  there  are  no  dyspeptic 
symptoms,  and  the  patient  declares  that  nothing  disagrees  with 
him.  In  such  cases  the  complexion  is  usually  florid,  the  skin 
acts  freely,  the  tongue  is  clean,  the  action  of  the  bowels  regu- 
lar, and  the  urine  clear  ;  and  the  only  noticeable  indications  of 
declining  health  are  fretfulness  or  irritability  of  temper,  with 
depression  of  spirits,  coldness  of  the  extremities,  feebleness  of 
the  pulse,  and  pale  or  almost  colorless  urine,  remarkable  for 
the  extreme  lowness  of  its  specific  gravity.  But  more  generally 
the  complexion  is  sallow  and  the  skin  sluggish,  and  evidence  of 
mischief  is  furnished  by  yellowness  of  the  conjunctivae,  consti- 
pation of  the  bowels,  a  pale  and  unhealthy  character  of  the 
dejections,  excessive  flatulerfce  after  meals,  turbidity  of  the 
urine,  feebleness  of  the  pulse,  and  slow  yet  steady  enlargement 
of  the  joints — an  enlargement  which  in  many  cases  is  unac- 
companied by  perceptible  increase  of  local  action,  and  appears 
to  depend  upon  a  process  allied  to  slow  perversion  of  nutrition, 
rather  than  to  ordinary  active  inflammation.  Yet  so  obstinate 
does  it  generally  prove  in  its  continuance,  and  such  thickening 
does  it  produce  in  the  periosteum  covering  the  extremities  of 
the  bones,  in  the  ligamentous  structures,  in  the  synovial  mem- 
brane, and  in  the  bursre  and  sheaths  of  tendons  immediately 
surrounding  the  joints,  that  more  or  less  permanent  stiffness 
and  enlargement  remain  long  after  all  active  disease  has  passed 
away.  A  second  or  third  attack  brings  out  in  relief  this  dis- 
tinctive feature.  The  irritation  of  a  poison  which  has  been 
attracted  to  the  joint  for  a  sufficient  length  of  time  to  cause 


DIAGNOSIS    OF    THE    DISEASE    IN    A    CHRONIC    FORM.       301 

effusion  into  the  synovial  membrane,  and  thickening  of  the  sub- 
synovial  areolar  tissue,  very  seldom  fails  to  excite  more  deep- 
seated  and  more  serious  mischief.  The  cartilages  with  which 
the  structures  in  question  are  intimately  connected  are  gen- 
erally implicated  sooner  or  later.  Their  nutrition  becomes 
affected,  and  gradual  absorption  of  their  structure  takes  place ; 
and  thus,  after  a  time,  the  articular  surfaces  of  the  bone  are 
left  bare  and  unprotected.  But  more  than  this.  While  the 
ligaments  which  keep  the  extremities  of  the  bone  in  apposition 
are  being  stretched  by  the -fluid  effused  within  the  joint,  and 
the  cartilages  at  the  same  time  are  gradually  wasting,  the 
extremities  of  the  bones  themselves  become  irregularly  en- 
larged by  expansion  of  their  osseous  tissue,  and  the  deposit  of 
osseous  matter  around  the  joint. ^  A  material  alteration  is 
thus  produced  in  the  form,  and  oftentimes  in  the  direction  of 
the  joint.  The  fingers,  for  instance,  which  are  very  prone  to 
be  affected,  are  drawn  toward  the  ulnar  or  outer  side  of  the 
hand,  and  take  a  permanently  oblique  direction  ;  while  the 
enlarged,  and  partly  dislocated  extremities  of  the  bones,  more 
especially  of  the  metacarpal  bones,  project  in  every  variety  of 
form,  and  constitute  the  "  nodosities"  which  have  been  described 
by  Dr.  Ilaygarth,  in  his  "  Clinical  History  of  Disease."^ 
Strange  as  it  may  seem,  these  changes  in  the  form  and  direc- 

1  "  The  great  distinction  of  this  process  from  ordinary  iiiHammation  con- 
sists in  this,  that  in  the  chronic  rheumatic  affection,"  as  Dr  Colles  has  well 
remarked,  '■  two  very  opposite  processes  are  to  be  found  going  on  at  the  same 
time,  viz.  :  absorption  of  the  old  bone  and  its  cartilage  of  incrustation,  with 
deposition  of  new  bony  matter,  while  in  the  ordinary  inflammation  there  would 
be  simply  a  gradual  enlargement  of  the  bone.  It  is  worthy  of  remark  that, 
in  malignant  disease  of  the  joints,  and  in  strumous  affections  of  thorn,  both 
connected  with  constitutional  taint,  there  is  the  same  tendency  to  the  forma- 
tion of  exuberant  osseous  growths  around  the  joints,  while  the  articular 
textures  within  are  suffering  destruction  and  decay."  (Todd  on  "  Rheumatism," 
p.  169.)  For  beautiful  illustrations  of  the  changes  thus  produced  in  the  joints, 
see  the  Atlas  which  accompanies  Dr.  Adams's  work  on  Rheumatic  Gout. 

*  I  am  glad  to  find  my  views  confirmed  by  Professor  Rokitancky,  who  gives 
it  as  his  opinion,  ("  Pathological  Anatomy,"  p  173,)  that  the  changes  in  ihese 
cases  are  not  due  to  simple  rheumatic  arthritis.  He  believes  them  to  have  more 
or  less  of  a  gouty  origin,  but  I  am  inclined  to  regard  them  as  referable  to  the 
agency  of  a  specific  poison  altogether  distinct  from,  though  closely  allied  to, 
the  materies  morbi  of  rheumatism  and  gout. 


302  RHEUMATIC    GOUT. 

tion  of  the  joints  are  strikingly  similar  on  either  side  of  the 
body,  each  knobby  enlargement  on  the  one  side  having  its 
counterpart  in  the  corresponding  joint  on  the  other,  so  that  an 
extraordinary  symmetry  of  arrangement  is  exhibited  in  the 
local  manifestations  of  the  disease. 

In  connection  with  this  enlargement  of  the  joints,  there  sel- 
dom exists  any  deposit  resembling  the  chalky  deposit  of  gout : 
indeed,  it  may  be  stated  that  no  such  deposit  is  ever  found, 
unless  at  some  time  or  another  the  patient  has  been  afflicted 
Avith  true  gout.  The  first  series  of  changes  are  usually  con- 
fined to  an  alteration  in  the  nutrition  of  the  parts  affected, 
which  causes  them  to  lose  their  natural  brilliancy  and  elastic- 
ity, and  to  become  thickened,  opaque,  and  altered  in  color. 
After  a  longer  period  of  exposure  to  the  irritation  of  the  rheu- 
matic element,  a  further  alteration  of  structure  takes  place  ; 
processes  of  thickened  synovial  membrane  are  seen  dipping 
down  into  depressions  existing  around  the  head  and  neck  of  the 
bones;'  or  a  dense  ligamentous  substance,  resulting  probably 
from  some  peculiar  alteration  in  the  synovial  membrane,  is  seen 
interposed  between  the  articulcating  surfaces;^  or  small  irreg- 
ularh'^-shaped  cartilaginous  bodies  are  found  existing,  either 
loose  within  the  joint,  or  attached  to  it  by  pedicles  formed  of 
thickened  synovial  membrane;^  or  the  opposed  surfaces  of  the 
bones  denuded  by  chronic  wasting  of  the  cartilages,  and  rend- 
ered smooth  by  attrition  upon  each  other,  are  found  white, 
glistening,  and  ivory-like  in  appearance.^ 

•  8ee  Dr.  Adams's  articles  in  the  '•  Cyclop;cdia  of  Anatomy  and  Physiology," 
as  also  the  Reports  of  Messrs.  Adams,  Canton,  and  Prescott  Hewett,  in  the 
'•  Transactions  of  the  Paihologrical  Society  of  London  " 

'^  A  case  illustrative  of  this  change  in  the  synovial  membrane  will  be  found 
in  Sir  Benjamin  Brodie's  "Observations  on  Diseases  of  the  Joints,"  p.  11. 
Specimens  illustrative  of  this  morbid  appearance  may  be  seen  in  the  Museum 
of  St.  George's  Hospital. 

^  For  a  full  description  of  the  minute  structure  of  these  bodies,  see  a  paper 
by  Mr.  Rainey,  quoted  in  the  "  Transactions  of  the  Pathological  Society  of 
London"  for  1848-40,  p  110  ;  also  Dr.  Adams's  treatise  on  Rheumatic  Gout, 
pp.  .S1-.34.  Some  beautiful  preparations,  exhibiting  these  bodies  in  situ,  may 
be  seen  in  the  Museum  of  St.  George's  Hospital. 

*  This  condition  has  been  described  and  delineated  by  Cruveilhier,  under 
the  title  of  "  Qsure  des  Cartilages."     Cases  in  point  are  recorded  in  Sir  B. 


\ 


MODE   OF    DETERMINING    THE    NATURE    OF   THE    DISEASE.    303 

But  in  some  cases,  which  in  external  appearance  present 
many  of  the  characteristics  of  the  disorder  I  am  describing, 
there  exists  a  deposit,  more  or  less  extensive,  of  a  white  pul- 
verulent matter.  Sometimes  this  matter  is  deposited  over  the 
■whole  extent  of  the  articulating  surfaces,  so  that  the  cartilages 
appear  smoothly  incrusted  by  it ;  at  others,  it  is  sparingly 
sprinkled  over  their  surface  in  the  form  of  a  fine  white  powder ; 
at  others,  it  is  limited  to  a  few  parts  only;  and  at  others,  again, 
it  not  only  covers  their  entire  surface,  but  pervades  their  struc- 
ture, and  fills  the  cancelli  of  the  subjacent  bone.^  That  this 
deposit,  which  analysis  has  shown  to  consist  of  lithate  of  soda, 
mixed  occasionally  with  some  lithate  of  potash,  ammonia,  and 
lime,  as  also  with  chloride  of  sodium,  and  with  phosphate  and 
carbonate  of  lime,^  is  identical  in  composition  with  the  deposit 
which  exists  in  gout,  and  that  it  occurs  in  those  cases  only  of 
rheumatic  gout  which  in  their  external  symptoms  approximate 
most  closely  to  genuine  gout,  is  susceptible  of  easy  proof;  and 
it  does  not  admit  of  doubt  that  its  presence  in  the  joints  is  con- 
clusive evidence  of  the  existence  of  true  gout  at  some  period  or 
another  of  the  patient's  life.  But  I  cannot,  therefore,  admit 
the  conclusion,  that  the  existence  of  such  deposit  is  of  itself 
sufficient  to  mark  such  cases  as  examples  throughout  of  true 
gout;  for  it  often  occurs  in  persons  who,  in  their  younger  days, 
have  been  martyrs  to  rheumatic  gout  in  its  distinctive  form; 
and  it  sometimes  coexists  with  those  structural  changes  in  the 
joints  which  everybody  admits  to  be  dependent  upon  rheumatic 
gout.  Thus,  among  cases  which  do  not  diifer  greatly  from 
each  other  in  their  external  character,  there  are  found,  in  some, 

Brodie's  work  "  On  the  Joints,"  ed.  4,  p.  322,  as  also  in  the  "  Transac- 
tions uf  the  Pathological  JSociety.''  Specimens  are  preserved  in  the  Museum 
of  St.  George's  Hospital. 

1  See  Report  by  Dr.  Handfield  Jones,  in  the  "  Pathological  Transactions'' 
for  1848-9. 

'■*  This  was  distinctly  proved  in  some  cases  of  Dr.  Chambers's,  as  also  in  a 
case  of  Mr.  Stanley's,  ofSt.  Bartholomew's  Hospital,  (reported  by  Sir  C.  Scud- 
amore,  in  his  work  on  "Rheumatism,"  p.  351,)  in  which  the  deposit  consisted 
almost  entirely  of  carbonate  of  lime.  Specimens  of  the  joints  are  preserved 
in  the  Hospital  Museum.  For  the  result  of  several  analyses  of  the  ordinary 
tophacious  deposits,  see  Simon's  "Chemistry,"  vol.  ii,  p.  4TT. 


304  RHEUMATIC    GOUT. 

extensive  structural  alterations  in  the  joints,  but  no  traces, 
however  slight,  of  earthy  deposit;  in  others,  the  same  altered 
condition  of  the  articulations  is  accompanied  by  an  evident, 
though  scanty  and  irregular  earthy  doposit;  Avhile  in  others, 
again,  the  deposit  is  extensive,  and  the  structural  changes  first 
alluded  to,  comparatively  small.  In  the  more  extreme  examples 
of  the  disease  it  is  not  difficult  to  determine  whether  the  case 
be  one  of  gout  or  rheumatic  gout,  and  to  predict  with  tolerable 
accuracy  whether  any  deposit  will  or  will  not  be  discovered  in 
the  joints  after  death  ;  but  in  some  few  instances  the  symptoms 
are  of  such  a  hybrid  character  as  to  preclude  the  possibility  of 
arriving  at  any  certain  conclusion.  Even  dissection  fails  some- 
times to  disclose  any  strongly-marked  difference  between  those 
cases  which  are,  and  those  which  are  not,  accompanied  by  such 
deposit ;  for  occasionally  one  joint  may  be  found  smeared  over 
with  earthy  matter,  while  another  in  the  same  patient,  equally 
enlarged,  presents  no  appreciable  amount  of  deposit.  Of  this 
I  have  seen  two  instances ;  and  as  it  is  quite  possible  for  a  gouty 
tendency  to  be  engrafted  on  an  old  rheumatic  gout  disposition, 
or  for  a  rheumatic  gout  tendency  to  arise  in  a  gouty  habit,  I 
have  come  to  the  conclusion  that  in  such  cases,  which  are  very 
rare,  the  disease  has  been  at  one  time  rheumatic  gout,  at  another 
more  strictly  gouty  in  its  nature,  and  that  the  difference  in  the 
results  observed  after  death  has  arisen  from  the  prevalence 
of  each  form  of  disease  at  different  periods  of  the  patient's 
life. 

I  trust  it  is  made  sufficiently  clear,  by  the  above  statement, 
that  the  disease  should  not  be  regarded  as  of  a  hybrid  charac- 
ter, or,  in  other  words,  made  up  in  part  of  rheumatism,  in  part 
of  gout.  It  is  my  firm  conviction,  that  just  as  the  true  rheu- 
matism and  true  gout  do  both  sometimes  manifest  themselves  at 
different  periods  of  life  in  the  same  individual,  so  rheumatic 
gout  may  arise  in  a  person  who  either  has  been,  or  may  here- 
after become,  subject  to  true  rheumatism  or  true  gout,  and  that 
it  has  no  connection  with  either  of  these  diseases,  beyond  that 
which  attaches  to  it  in  virtue  of  its  being  a  constitutional  dis- 
order, producing  local  manifestations  in  the  joints.       Not  only 


MODE    OF    DETERMINING    THE    NATURE    OF    THE    DISEASE.    305 

does  analysis  of  the  blood,  and  of  tlie  fluid  eflused  into  the  joints 
in  these  cases,  when  well  marked  and  distinctive,  prove  the  ab- 
sence of  lithic  acid,  the  poison  of  gout,  as  a  cause  of  the  articu- 
lar inflammation  and  enlargement,  but  the  rare  occurrence  of 
an}''  goutj  deposit  in  the  joints,  in  cases  answering  to  my  de- 
scription of  rheumatic  gout,  renders  it  manifest,  even  to  a 
superficial  observer,  that  the  presence  of  true  gouty  symptoms 
il  a  mere  coincidence,  and  by  no  means  essential  to  the  exist- 
ence of  the  disease.  On  the  other  hand,  analogy  furnishes 
strong  grounds  for  the  belief-  that  the  articular  mischief  is  not 
due  to  the  presence  of  lactic  acid,  or  whatever  may  be  the  mate- 
ries  morbi  in  true  rheumatism,  while  the  rapidity  with  which 
structural  disorganization  of  the  joints  supervenes,  even  when 
the  local  action  is  apparently  least  acute,  and  when  the  gen- 
eral symptoms  are  certainly  not  indicative  of  febrile  disturb- 
ance, is  a  further  proof  that  it  is  essentially  distinct  from  true 
rheumatism,  as  typified  in  rheumatic  fever,  or  in  the  ordinary 
chronic  form  of  the  disease.  Indeed,  the  circumstances  under 
which  rheumatic  gout  occurs,  the  extraordinary  obstinacy  of  its 
symptoms,  the  peculiar  alteration  in  the  structure  of  the  joints, 
which  forms  its  most  characteristic  feature,  and  the.  class  of 
remedies  by  which  it  is  most  successfully  combated,  all  seem  to 
indicate  a  close  connection  with  some  peculiar  constitutional 
taint.^  The  able  researches  of  Dr.  Gairdner^  have  rendered  it 
extremely  probable  that  true  gout  is  in  some  way  connected 
with  a  variation  in  the  relative  quantities  of  urea  and  uric  acid 
in  the  system,  and  hereafter  it  may  be  discovered  that  rheu- 
matic gout  is  dependent  on  some  other  perversion  in  the  rela- 
tive proportions  of  the  constituents  of  the  blood.  And  if  this 
be  so;  if,  in  short,  the  disease  be  due  to  a  disordered  condition 
of  the  blood  essentially  distinct  in  its  character  from  that  which 
gives  rise  to  pure  gout  or  to  pure  rheumatism,  we  are  bound  in 
accordance  with  sound  pathology  to  separate  it  from  the  dis- 
eases it  so  much  resembles,  and  with  which  it  is  sometimes  in- 
timately blended ;  to  trace  out  its  peculiarities  ;  and  to  estab- 

1  See  note,  p.  301.  '^  On  Gout. 


306  RHEUMATIC    GOUT. 

lish,  if  possible,  by  chemical  demonstration,  its  claim  to  be  con- 
sidered a  special  disorder. 

When  the  superficial  joints  are  attacked  by  this  disease,  the 
symptoms  already  described  will  generally  enable  us  to  recog- 
nize its  true  character.  But  all  joints  are  liable  to  its  invasion, 
and  when  those  which  are  deep  seated  suiFer,  the  diagnosis  is 
much  more  diiBcult  and  uncertain.  This  is  more  particularly 
the  case  when  the  hip-joint  is  the  part  implicated.  Local  paiH, 
or  a  sense  of  stiflTness  unaccompanied  by  heat,  or  by  any  ma- 
terial constitutional  disturbance,  is  usually  the  first  symptom  to 
attract  attention,  and  oftentimes  considerable  alteration  in  the 
joint  will  have  occurred  before  steps  are  taken  for  its  relief. 
As  the  disease  progresses,  the  pain  becomes  more  constant  and 
severe,  and  is  felt  most  acutely  when  the  weight  is  thrown  on 
to  the  affected  joint.  After  a  time,  other  symptoms  arise  de- 
pendent on  the  changes  progressing  within  the  joint.  For,  in 
the  hip,  as  in  the  other  joints,  the  disease  is  attended  by  the  de- 
posit of  ossific  matter  around  the  head  of  the  bone,  with  grad- 
ual wasting  of  the  cartilages,  and  eburnation  of  the  opposed 
articulating  surfaces.  And,  as  the  bony  deposits  take  place 
irregulyly,  the  shape  of  the  acetabulum  and  head  of  the  femur 
is  altered,  as  is  also,  not  unfrequently,  the  position  of  the  head, 
in  relation  to  the  neck  of  the  bone.  This,  together  with  ab- 
sorption of  the  cartilages,  leads  to  so  much  shortening  of  the 
affected  limb,  and  renders  rotation  of  the  thigh  so  difficult,  that 
the  patient  walks  lame,  and  presents  an  exceedingly  awkward 
appearance.  The  nates  of  the  affected  side  become  flattened, 
and  the  muscles  of  the  thigh,  in  some  measure,  atrophied  from 
want  of  use ;  the  foot  is  everted,  and  sometimes  the  toes  only 
can  be  placed  on  the  ground  ;  while,  from  the  difficulty  or  im- 
possibility of  rotating  the  leg,  circumduction  of  the  limb  is 
rendered  necessary. 

The  symptoms  just  described,  point  unequivocally  to  mis- 
chief in  the  hip,  yet,  as  this  affection  is  usually  limited  to  the 
one  hip,  and  rarely  extends  to  other  articulations,^  the  unwary 
might  be  led  to  attribute  the  mischief  to  some  other  and  a 
^  See  "  Cyclopaedia  of  Anatomy  and  Physiology,"  article  *^Hip." 


TREATMENT  OF  THE  ACUTE  FORM.  307 

purely  local  cause.  But  careful  inquiry  into  the  history  of  the 
case  will  seldom  fail  to  unveil  the  mystery.  Generally  the 
patient  will  bo  found  to  have  suffered  from  rheumatic  gout  at 
some  former  period ;  or  to  have  experienced  pain  recently  in 
some  of  his  other  joints ;  or,  possibly,  to  have  had  slight  tem- 
porary swelling  in  the  knee,  or  in  one  of  his  toes  or  knuckles; 
and  thus  a  clew  to  the  nature  of  the  disease  will  be  obtained  at 
once,  and  may  be  safely  acted  on.  Indeed,  such  a  discovery  is 
of  great  practical  importance,  inasmuch  as  it  often  leads  to  the 
employment  of  remedies  addressed  to  the  relief  of  constitutional 
derangement,  when  otherwise  the  treatment  might  have  been 
purely  local. 

The  treatment  required  in  the  acute  form  of  rheumatic  gout 
differs  from  that  of  rheumatism,  in  that,  from  the  character  of 
the  persons  attacked,  it  need  seldom  be  actively  antiphlogistic, 
and  from  the  inflammation  of  the  joints  being  more  stationary, 
and  the  danger  of  structural  disorganization  greater,  there  is 
more  necessity  for  the  application  of  leeches,  blisters,  and 
fomentations  to  the  inflamed  parts.  General  venesection  is 
rarely,  if  ever,  needed  in  this  form  of  disease,  even  when  most 
acute,  and  opium,  as  was  pointed  out  by  Dr.  Corrigan,^  is  of 
far  less  importance,  than  in  genuine  rheumatism.  Even  alkalies 
are  not  needed  in  such  full  doses  as  in  acute  rheumatism,  and 
when  so  employed,  are  apt  to  prove  depressing ;  but  given  in 
moderate  quantity  with  colchicum,  small  doses  of  antimony, 
and  alterative  doses  of  blue  pill  or  calomel,  aided  by  an  occa- 
sional warm  or  vapor  bath,  some  mild  purgative,  topical  appli- 
cations to  the  joints,  and  strict  attention  to  diet,  are  usually 
sufficient  for  the  relief  of  its  more  active  symptoms.  • 

When  speaking  of  the  treatment  of  acute  rheumatism,  T  en- 
tered fully  into  the  consideration  of  all  the  circumstances  which 
indicate  the  employment  of  these  various  remedies,  and  which 
render  their  use  inadmissible,  and  I  do  not  know  that  anything 

1  "There  is  one  form  of  acute  rheumatism,"  he  says,  ''in  which  the  opiate 
treatment  will  cause  disajjpointment,"  it  is  that  in  which,  "  when  rheumatism 
does  appear,  it  is  not  genuine  rheumatism,  but  a  combination  of  gout  with 
rheumatism."     ("  Dublin  Medical  Journal,"  vol.  xvi,  p.  267.) 


308  RHEUMATIC    GOUT. 

will  be  gained  by  a  reiteration  of  cautions  which  hold  good  as 
well  in  this  form  of  disease  as  in  that  we  were  then  consider- 
ing. Colchicum'  and  alkalies  are  as  necessary  here  as  in  gen- 
uine rheumatism,  and  as  the  chylopoietic  viscera  are  generally 
sluggish,  and  the  secretions  much  deranged,  energetic  medical 
interference  is  needed  to  restore  them  to  a  healthy  condition. 
But  in  the  administration  of  remedies,  the  greatest  care  should 
be  taken  not  to  depress  the  system  unnecessarily;  if  in  genuine 
rheumatism  this  caution  is  needful,  much  more  so  is  it  here, 
where  the  disease  occurs  in  the  weakly  or  cachectic,  and  ex- 
hibits a  remarkable  tendency  to  pass  into  a  chronic  form. 
Whether  mercury  and  purgatives,  or  colchicum  be  employed, 
care  must  be  taken  so  as  to  administer  the  medicines  as  to 
remedy  defective  secretion,  eliminate  the  poison,  and  restore  a 
healthy  state  of  assimilation  without  lowering  the  patient,  and 
exhausting  his  strength.  The  whole  energy  of  his  constitution 
may  be  needed  to  bear  up  against  the  protracted  irritation 
arising  from  chronic  inflammation  of  the  joints,  and  even  if  he 
escape  articular  disorganization,  nothing,  in  my  experience,  so 
greatly  tends  to  endanger  recovery,  nothing  assists  so  much  in 
perpetuating  the  rheumatic  state,  as  over-active  and  depressing 
treatment. 

Sometimes,  however,  a  slightly  antiphlogistic  treatment 
seems  imperatively  called  for,  by  the  obstinacy  of  the  local 
symptoms,  and  the  long  continuance  of  febrile  disturbance. 
The  cases  alluded  to  are  characterized  by  more  than  ordinary 
derangement  of  the  digestive  function,  an  unhealthy  condition 
of  the  intestinal  secretions,  and  excessive  sluggishness  of  the 
•  liver.  There  is  acidity  of  the  stomach,  with  a  foul  tongue,  and 
a  disagreeable  sour  taste  in  the  mouth,  and  the  dejections  are 
dark  colored  and  offensive,  or  else  pale  and  deficient  in  healthy 
bile.  In  some  cases,  the  action  of  a  brisk  emetic  so  completely 
modifies  the  character  of  the  secretions,  and  exercises  so  much 
influence  for  good,  as  to  render  active  treatment  unnecessary  ; 

1  In  some  examples  of  this  form  of  disease  I  liave  found  the  tincture  of  the 
flowers  of  colchicum  extremely  beneficial,  even  when  other  preparations  have 
failed. 


REMEDIES   WHICH    PROVE    MOST    USEFUL.  309 

but  when  it  fails  to  do  so,  it  is  especially  needful  to  get  rid  of 
the  disordered  accumulations  in  the  bowels,  and  to  stimulate  the 
whole  secreting  apparatus  of  the  intestines  by  alteratives  and 
laxatives  judiciously  administered.  For  this  purpose  nothing 
answers  better  than  small  doses  of  blue  pill,  or  of  calomel  in 
combination  with  opium  and  acetous  extract  of  colchicum,  fol- 
lowed by  a  senna  or  rhubarb  draught,  containing  carbonate  of 
magnesia  to  neutralize  any  free  acid  existing  in  the  stomach  ; 
and  if  small  bleedings  be  employed,^  and  antimony  given,  while 
a  full  action  is  thus  maintained,  the  intensity  of  the  febrile 
action  is  speedily  mitigated,  and  the  patient  is  brought  into  a 
atate  to  benefit  by  other  remedies.  Cases  which  prove  intract- 
able by  alkalies,  colchicum,  and  mercury,  yield  readily  to  their 
influence  after  the  febrile  action  has  been  subdued  by  the  means 
just  alluded  to.^ 

In  some  instances,  lemon-juice  proves  a  valuable  ally  in  the 
treatment  of  this  form  of  disease,  more  especially  when  the 
patient  is  cachectic  or  scorbutic,  and  has  lived  almost  exclu- 
sively on  animal  or  farinaceous  food,  in  foolish  dread  of  whole- 
some vegetables.  Whether  it  be  by  its  direct  influence  on  the 
digestion,  or  by  supplying  some  needful  material  to  the  blood, 
lemon-juice,  in  many  cases,  undoubtedly  assists  in  accelerating 
a  cure.  In  hospital  practice,  as  well  as  in  private  life,  I  have 
had  repeated  opportunities  of  noting  this  fact,  and  in  several 
instances  the  improvement  which  has  followed  has  been  most 
marked  and  rapid.  Therefore,  whenever  the  sponginess  of 
the  gums  or  the  history  of  the  patient  leads  me  to  suspect  the 
existence  of  one  of  the  conditions  referred  to,  I  order  lemonade 
made  with  the  juice  of  one  or  two  lemons  to  be  taken  daily  as 
a  beverage,  in  addition  to  other  remedies.  It  is  of  little  or  no 
service  when  the  urine  is  clear,  pale,  and  abundant,  but  when 
it  is  scanty,  high  colored,  and  loaded,  it  so  often  proves  useful 

^  Not  more  than  from  ^iv  to  §vj  of  blood  sbould  be  taken  in  these  cases. 

^  Dr  Graves,  in  alluding  to  this  class  of  cases,  remarks,  "Cases  of  rheu- 
matic arthritis,  attended  with  prolonged  excitement  of  the  circulation  and 
copious  sweating,  are  generally  found  to  exhibit  an  intractable  chronicity,  and 
too  often  terminate  in  rendering  the  unfortunate  patient  a  cripple  for  life." 
(•'  Clinical  Medicine,"  ed.  2,  vol.  i,  p.  488.) 


310  RHEUMATIC    GOUT 

in  promoting  diuresis  and  effecting  a  salutary  change  in  the 
system,  that,  Avhatever  the  prior  history  of  the  patient,  1  gener- 
ally recommend  its  being  taken  in  the  manner  pointed  out.  If 
its  flavor  rises  in  the  mouth  long  after  it  has  been  taken,  it 
manifestly  disagrees,  and  its  use  must  be  discontinued  ;  but  if 
not,  its  administration  should  be  steadily  persisted  in. 

In  most  instances  the  early  and  assiduous  employment  of 
appropriate  fomentations  Avill  prevent  the  occurrence  of  articu- 
lar mischief,  and  obviate  the  necessity  for  more  active  local 
remedies.  If,  directly  inflammation  of  a  joint  is  set  up,  that 
joint  be  kept  at  rest  and  constantly  bathed  in  a  warm  solution 
of  potash  and  opium,  I  am  satisfied,  from  repeated  observation, 
that  no  other  toj)ical  application  will  be  needed.  But  the 
neglect  of  this  simple  and  rational  precaution  exposes  the 
structures  to  the  mischievous  eff'ect  of  excessive  and  protracted 
irritation,  and  renders  probable  the  occurrence  of  actions 
requiring  other  measures  for  their  subjugation. 

No  doubt  can  exist  as  to  the  vast  importance  of  protecting 
the  joints  from  permanent  mischief,  and  therefore,  when  the 
disease,  from  whatever  cause,  does  show  a  disposition  to  fix 
itself  in  a  particular  locality,  immediate  steps  should  be  taken 
for  its  relief.  Local  depletion,  if  had  recourse  to  early,  is 
folloAved  by  speedy  abatement  of  pain  and  swelling,  and  even 
in  subacute  and  lingering  cases,  or  at  a  later  period  of  the 
attack,  will  still  aff'ord  considerable  benefit.  But  it  is  usually 
necessary  to  employ  counter-irritation  in  order  to  eff'ect  a  com- 
plete removal  of  the  mischief.  When  much  eff"usion  or  thick- 
ening has  taken  place,  something  more  than  mere  local  depletion 
is  needed  to  restore  the  parts  to  a  healthy  condition.  After 
cupping  and  leeches  have  fairly  done  their  work  in  unloading 
the  congested  vessels  and  arresting  the  further  progress  of 
eff'usion,  blisters  maintain  the  good  efi"ects  produced,  and 
remove  the  evil  consequent  on  the  action  which  has  already 
taken  place.  A  cure  which  is  impracticable  by  leeches  alone, 
becomes  practicable  and  easy  by  the  joint  application  of  leeches 
and  blisters. 

When  once  it  becomes  necessary,  from  the  nature  of  the  local 


APPROPRIATE    REMEDIES.  311 

mischief,  to  have  recourse  to  such  remedies,  they  can  hardly 
be  employed  too  vigorously  or  too  constantly.  Half  a  dozen 
leeches  should  be  applied  for  several  successive  days,  and 
should  be  followed  by  blisters,  repeated  until  all  symptoms  of 
mischief  shall  have  subsided.  In  the  mean  time  the  affected 
parts  should  be  kept  perfectly  quiet.  If  the  wrist  be  implicated, 
a  splint  should  be  applied,  and  fastened  on  by  bandages  passed 
over  the  fingers  and  round  the  arm,  above  the  seat  of  inflam- 
mation. While  perfect  freedom  from  jnotion  is  thus  insured, 
the  wrist  itself,  uncovered,  is'  open  for  examination,  and  ready 
for  the  application  of  remedies.  In  like  manner  should  the 
knees,  the  ankles,  or  the  elbows  be  involved,  it  is  often  of 
service  to  adopt  some  such  measures  as  those  just  alluded  to, 
in  order  to  insure  repose. 

There  is  one  class  of  remedies  which,  in  acute  rheumatic 
gout,  as  in  many  cases  of  genuine  rheumatism,  are  frequently 
of  essential  service  ;  I  mean  vapor  and  hot-air  baths,  and  warm 
baths  of  various  descriptions.  They  promote  perspiration  to 
an  extraordinary  degree,  and  unload  the  system  without  greatly 
depressing  it.  Hence  in  those  instances  which  are  marked  by 
harshness  and  dryness  of  the  skin,  they  prove  of  inestimable 
value.  One  species  of  bath,  which  from  the  nature  of  the  case 
it  is  difficult  to  make  use  of  during  a  paroxysm  of  acute  rheu- 
matism, may  be  employed  in  this  complaint  with  great  advant- 
age, namely,  the  warm  bath  rendered  alkaline  by  the  addition 
of  a  pound  of  the  carbonate  of  soda  or  carbonate  of  potash. 
The  value  of  this  auxiliary  in  combating  the  disease,  has  been 
ably  pointed  out  by  Dr.  Wright,  of  Birmingham  ;^  and  within 
my  oAvn  experience  many  cases  which  have  long  resisted  oi'di- 
nary  treatment,  have  yielded  readily  as  soon  as  this  alkaline 
bathing  has  been  commenced.  It  certainly  possesses  virtues 
which  do  not  attach  to  the  simple  warm  bath,  and  I  believe  its 
peculiar  efficacy  is  attributable  in  part  to  the  local  action  of 
the  salt  in  stimulating  the  action  of  the  skin,  and  in  part  to 
absorption  of  the  alkali  into  the  blood.  Repeated  on  alternate 
days,  or  daily  when  the  skin  is  sluggish  in  its  action,  a  bath  of 

1  Lectures  published  in  the  "  Medical  Times"  for  June,  1847. 


812  RHEUMATIC    GOITT. 

this  description  appears  not  only  to  mitigate  the  severity  of  the 
local  symptoms,  but  to  promote  a  free  secretion  from  the  skin, 
the  liver,  and  the  kidneys,  and  so  to  be  conducive  to  the  resto- 
ration of  health. 

The  foregoing  observations  have  been  confined  to  the  treat- 
ment of  the  disease  as  it  is  met  with  in  the  more  vigorous,  and 
in  those  who  heretofore  have  been  free  from  its  invasion.  In 
such  persons  there  is  evidence  of  active  febrile  disturbance  ;  the 
skin  is  often  hot,  the  tongue  furred,  the  urine  loaded  ;  and  as 
the  excretory  organs  are  in  a  condition  to  answer  to  the  stimu- 
lus of  medicine,  nothing  answers  better  to  check  the  further 
formation  of  the  poison,  to  promote  the  elimination  of  that 
which  has  been  already  generated,  and  to  restore  a  healthy 
state  of  assimilation,  than  the  treatment  above  described.  But 
we  are  more  frequently  called  upon  to  administer  relief  to  those 
whose  enlarged  and  distorted  joints  give  abundant  evidence  of 
long-standing  mischief,  or  whose  sallow  complexion  attests  the 
long  continuance  of  general  derangement.  To  such  persons 
the  remedies  already  specified  afford  but  little  and  only  tempo- 
rary abatement  of  suffering.  In  them  the  whole  conditions  of 
the  case  are  altered.  The  skin  is  usually  cool,  and  is  moist  and 
clammy,  or,  if  not,  is  harsh  and  unperspiring  ;  the  tongue  is  but 
slightly  coated  ;  the  pulse  weak  and  irritable  ;  and  the  urine 
abundant,  pale  colored,  and  of  Tow  specific  gravity,  sometimes 
containing  a  trace  of  albumen  ;  all  of  which  symptoms  point 
most  significantly  to  the  presence  of  a  small  quantity  only  of 
the  poison,  and  to  a  defective  condition  of  the  excretory  organs 
as  the  principal  cause  of  its  accumulation  in  the  system.  Hence 
medicines  which  prove  serviceable  to  the  one  class  of  patients, 
are  found  useless  to  the  other  whose  excretory  organs  are 
faulty  or  inactive.  They  often  produce  alarming  depression 
without  fulfilling  the  object  of  their  administration.  In  these 
cases,  therefore,  another  class  of  remedies  has  to  be  called  to 
our  aid.  As,  by  giving  diuretics  and  other  medicines  which 
act  as  direct  stimuli  to  the  kidneys  and  liver,  we  are  unable 
permanently  to  affect  the  character  of  the  secretions,  we  must 
endeavor  to  improve  the  tone  of  the  system  generally,  and  so 


AS    IT    APPEARS    IN    THE    WEAKLY    AND    CACHECTIC.       313 

to  render  the  excretory  organs  more  eflBcient  in  their  action. 
Meanwhile  we  must  relieve,  as  best  we  may,  the  more  urgent 
symptoms  of  the  disease,  by  acting  upon  the  skin  and  making 
it  perform  the  extra  duty  which  devolves  upon  it  in  consequence 
of  the  inactivity  of  the  other  organs. 

The  means  by  which  these  ends  may  be  accomplished  assume 
different  aspects  under  different  circumstances.  In  general,  a 
combination  of  bark,  sarsaparilla,  iodide  of  potassium,  and 
liquor  potassse,  when  aided  by  change  of  scene  and  air,  active 
exercise,  judicious  bathing,  and  constant  friction,  proves  one 
of  the  most  efficient  means  of  rousing  the  dormant  energies  of 
the  system,  and  restoring  the  power  of  the  excretory  organs.^ 
In  many  instances  the  happiest  results  are  obtained  from  this 
plan  of  treatment  when  steadily  and  properly  persevered  in. 
I  have  seen  case  after  case,  in  which,  under  this  treatment 
continued  for  some  months,  the  patient's  general  aspect  has 
improved,  his  complexion  has  become  clearer,  his  appetite  more 
regular,  the  pulse  stronger  ;  and  in  which,  coincidently  with 
this  injprovement  in  the  health,  there  has  been  a  corresponding 
alteration  in  the  character  of  the  excretions,  and  in  the  severity 
of  the  rheumatic  symptoms.  The  urine  has  regained  its  normal 
specific  gravity,  the  alvine  evacuations  have  reassumed  their 
healthy  bilious  appearance,  and  all  active  articular  symptoms 
have  subsided,  leaving  only  some  thickening  about  the  tendons 
and  ligaments. 

Sometimes,  however,  when  the  appetite  is  indifferent,  the 
tongue  clean,  the  urine  pale,  and  the  skin  clammy,  alkalies, 
even  when  combined  with  tonics,  do  not  appear  to  mitigate  the 
disorder.  Indeed,  they  seem  to  lower  the  general  tone  of  the 
system,  and  thus  indirectly  to  aggravate  existing  mischief. 
The  appetite,  already  indifferent,  fails  altogether  ;  a  sense  of 
exhaustion  and  nervous  depression  ensues,  and  the  pains  and 
swellings  increase.     Under  these  circumstances,  the  mineral 

1  The  formula}  I  usually  employ  are: 
Tincturae  Cinchonae  co.,  5Jss  ;  or  else  Liquoris  Potassaj,  n^xlv. 
Liquoris  Potassaj,  v\kI\-  ;  Potassii  lodidi,  gr.  v-x  ; 

Potassii  lodidl,  gr.  v-x  ;  Extract!  Sarzae,  5J  '• 

Decocti  Sarzse  co.,  ^iij,  ter  die.  Decocti  Cinchonae,  3x1,  ter  die. 

21 


314  RHEUMATIC    GOUT. 

acids  in  full  doses,  combined  with  bark,  quinia,  strychnia,  or 
other  vegetable  bitters,  and  aided  bj  the  daily  use  of  the  cold 
shower  bath,  prove  in  many  cases  valuable  and  trustworthy 
remedies.^  Indeed,  I  know  of  no  combination  of  remedial 
agents  in  the  persevering  use  of  which  I  place  so  much  con- 
fidence. Many  patients,  whose  symptoms  have  long  resisted 
the  influence  of^uaiacum,  iodide  of  potassium,  colchicum,  and 
every  vaiiety  of  alkaline  and  alterative  treatment,  and  who 
have  been  brought  to  me  crippled  by  long-standing  pain  and 
enlargement  of  their  joints,  have  regained  their  health,  and 
got  rid  of  their  disease,  under  this  treatment.  The  principal 
conditions  essential  to  its  success  are,  that  the  remedies  shall . 
be  tolerated  or  assimilated  by  the  stomach ;  and  that  during 
the  period  of  their  administration  the  secretions  shall  be  care- 
fully watched,  and  a  gentle  purgative  and  alterative  pill  given, 
if  turbidity  of  the  urine,  or  a  pale  or  abnormally  dark  color  of 
the  alvine  evacuations,  appears  to  indicate  biliary  or  renal  de- 
rangement. If  the  biliary  secretions  are  healthy,  and  the 
stomach  does  not  rebel,  cod-liver  oil  is  a  useful  adjunct  to  the 
mixture. 

In  some  instances,  however,  the  stomach  is  so  much  de- 
ranged, that  it  will  not  tolerate  bark  or  other  tonics ;  and, 
under  such  circumstances,  an  emetic  forms  an  admirable  pre- 
cursor of  other  remedies,  and  does  much  toward  preparing 
the  way  for  their  administration.  On  several  occasions  I  have 
known  the  appetite  to  return,  the  digestive  function  improve, 
and  the  excretory  organs  reassume  their  due  activity,  under 
the  influence  of  medicines  which,  prior  to  the  action  of  an 
emetic,  had  proved  quite  inoperative. 

In  most  of  the  cases  in  which  tonics  disagree  the  liver  is  very 

1  The  following  are  formulas  I  often  employ-,  viz. : 
Acidi  Nitrici ;  Or,  Sulphatis  Strychnia;,  gr.  ^ig  ; 

Acidi  Hydrochlorici,  aa  tHiij-v  ;  Acidi  Nitrici ; 

Quinaj  Disulphatis,  gr.  ij  ;  Acidi  Hydrochlorici,  aa  'm.'ij-v  j 

Tincturae  Arnicte  Montanae,  Tt^xxv ;     Tinct.  Arnica;  Montanae,  TUxxv  ; 
Syrupi  Aurantii,  3''iss :  Syrupi  Aurantii,  5"'ss; 

Decocti  Cinchonae,  §j  ;  Infiisi  Aurantii,  Co.,  §j : 

M.  ft.  Haustus  ter  die  sumendus.  M.  ft.  Haustus  ter  die  sumendus. 


TREATMENT    OF    THE    CHRONIC    FORM.  315 

sluggish  in  its  action,  and  the  secretions  of  the  bowels  are 
unhealthy ;  consequently,  during  the  administration  of  these 
remedies,  it  is  necessary  to  employ  some  gentle  laxative.  Calo- 
mel, and  indeed  every  form  of  mercury,  is  apt  to  prove  exceed- 
ingly depressing,  so  instead  of  having  recourse  to  its  adminis- 
tration, it  often  becomes  advisable  to  prescribe  a  pill  containing 
four  or  five  grains  of  oxgall,  or  else  a  morning  draught,  con- 
sisting of  some  light  bitter  infusion,  together  with  aloes  and 
extract  of  taraxacum.  Sometimes  taraxacum  is  of  such  service, 
that  I  rely  upon  it  even  to  a  greater  degree,  and  prescribe  an 
infusion  made  with  an  ounce  and  a  half  of  the  finely  sliced  root, 
to  eight  ounces  of  boiling  water,  to  be  taken  before  breakfast 
every  morning;  or  else  administer  from  half  a  drachm  to  a 
drachm  of  the  extract  three  times  a  day,  in  combination  with 
alkalies  and  the  infusion  of  gentian,  adding,  when  necessary,  a 
little  tincture  of  rhubarb,  or  half  an  ounce  of  the  compound 
decoction  of  aloes. 

In  cases  which  are  not  accompanied  by  much  hepatic  di^- 
rangement,  and  in  which  there  is  a  want  of  tone  in  tlie  system, 
with  depression  of  spirits,  coldness  of  the  extremities,  and  fre- 
quent clammy  weakening  perspiration,  the  greatest  benefit  is 
often  derived  from  the  cautious  use  of  the  shower  bath.  In- 
deed, among  the  younger  sufferers  from  this  complaint,  I  know 
of  no  single  remedy  so  generally  efficacious.  Even  when,  un- 
der ordinary  circumstances,  the  patients  lack  sufficient  vigor  to 
withstand  its  shock,  it  may  be  often  made  available  for  their 
relief  by  their  taking  it  while  standing  in  a  warm  bath  of  the 
temperature  of  98°,  in  which  they  have  been  previously  im- 
mersed, with  the  view  of  stimulating  the  cutaneous  circulation. 
But  those  persons  who  have  long  been  victims  to  this  disease, 
whose  conjunctivae  are  yellow,  and  who  present  other  symptoms 
of  biliary  derangement,  derive  greater  benefit  from  the  use  of 
the  vapor  or  hot-air  bath  cautiously  employed,  than  from  any 
other  external  remedy.  To  them  the  shower  bath  is  too  de- 
pressing; it  chills  and  exhausts  them,  and  is  not  followed  by 
the  salutary  glow  of  reaction  which  ensues  after  its  employ- 
ment in  the  younger  or  less  weakly.     The  warm  bath,  too,  if 


316  RHEUMATIC    GOUT. 

frequently  employed,  proves  equally  depressing,  and  often  fails 
in  giving  rise  to  that  flow  of  perspiration  wliich  is  found  so  efli- 
cacious  as  a  relief  to  the  sluggislily-acting  liver  and  kidneys ;  and, 
although  a  sulphuretted  and  alkaline  bath,'  or  a  simple  alkaline 
bath,  if  cautiously  employed  and  steadily  persisted  in,  is  often 
efficacious,  it  yet  proves  slow  in  producing  its  salutary  eff"ects. 
But  the  vapor  or  the  hot-air  bath,  if  not  made  use  of  too  fre- 
quently, and  persisted  in  for  too  long  a  period,  unloads  without 
greatly  depressing  the  system.  It  rapidly  produces  copious 
perspiration,  and  the  skin  thus  stimulated  to  vicarious  action, 
throws  off  a  vast  quantity  of  excrementitious  matter  which  for 
some  time  has  been  accumulating  in  the  blood.  Considerable 
relief  is  thus  obtained  during  the  interval  wh.ch  must  elapse 
before  the  medicine  can  fulfill  its  work  of  invigorating  the  sys- 
tem, and  restoring  the  functions  of  the  various  excretory  organs. 
In  eff"ecting  this  salutary  change  in  the  constitution,  the 
iodide  of  potassium  is  particularly  serviceable,  and,  therefore, 
unless  it  prove  depressing,  I  seldom  fail  to  recommend  its  ad- 
ministration in  three  or  four  grain  docs.  But  sometimes,  if  the 
appetite  is  pretty  good,  the  circulation  at  the  same  time  languid, 
and  the  skin  inactive,  the  patient  experiences  greater  relief 
from  its  exhibition  in  combination  with  the  mistura  guaiaci, 
than  with  the  mixture  before  alluded  to.  If,  in  such  a  case 
there  be  much  languor  and  debility,  and  bark  be  indicated,  it 
is  more  desirable  to  add  a  drachm  of  the  volatile  tincture  of 
guaiacum  to  the  bark  mixture,  than  to  substitute  guaiacum  en- 
tirely for  the  cinchona.  If,  again,  there  be  much  irritability  of 
the  stomach,  and  the  bark  induce  nausea  or  febrile  disturbance, 
quinia  is  an  admirable  and  eff"ective  substitute,  and  may  be  ad- 
ministered either  with  or  without  sulphate  of  magnesia,  accord- 
ing to  the  exigencies  of  the  case.     The  addition  of  fifteen  or 

1  The  subjoined  formula,  by  Messrs.  Planche  and  Boullay,  makes  an  excel- 
lent artificial  Sulphuretted  Bath  : 

Sulphide  of  Sodium  or  Potassium,  ^iij ; 

Carbonate  of  Soda,  5'j  ] 

Chloride  of  Sodium   5'jj 

Sulphate  of  Soda,  §j ; 

Distilled  Water,  Oj.  Mix,  and  then  add  to  the  mixture 
20  gallons  of  Water,  at  the  temperature  of  98°  Fahrenheit. 


TREATMENT    OF    THE    CHRONIC    FORM.  317 

twent}'  minims  of  the  dilute  sulphuric  acid  of  the  "  Pharmaco- 
poeia "  is  often  of  the  greatest  service.  By  such  variations  in 
the  combination  of  th(5se  remedies,  relief  may  be  obtained  in 
most  instances,  even  when  it  has  been  sought  in  vain  from  the 
exhibition  of  colchicum,  calomel,  and  the  whole  class  of  medi- 
cines which  prove  beneficial  in  acute  cases,  occurring  in  per- 
sons of  a  more  healthy  constitution. 

Occasionally,  however,  when  the  patients  are  pale  and  ex- 
sanguine, some  ferruginous  preparation  proves  a  more  efficient 
stimulus  and  tonic  than  bark  and  sarsaparilla.  The  Mistura 
Ferri  Composita  of  the  "Pharmacopoeia,"  the  Sesquioxide  of 
Iron,  the  Ferri  Potassio-Tartras,  the  Ferri  Ammonio-Citras, 
and  the  old-fashioned  steel  wine  are  all  excellent  preparations, 
and  may  be  administered  in  combination  with  other  medicines, 
according  to  the  circumstances  of  the  case.  In  some  instances, 
exceeding  benefit  is  derived  from  the  combination  of  iron  with 
cod-liver  oil.  A  drachm  of  the  syrup  of  iodide  of  iron,  or  fif- 
teen drops  of  the  muriated  tincture,  combined  with  three 
drachms  of  the  oil,  has  often  proved,  in  my  hands,  a  most  val- 
uable remedy  ;  and  in  no  single  instance  in  which  its  adminis- 
tration has  appeared  advisable,  has  the  slightest  ill  eff"ect  re- 
sulted from  its  exhibition.  But  throughout  the  period  of  its 
administration,  it  is  necessary  to  maintain  a  free  action  of  the 
skin,  and  to  pay  particular  attention  to  the  bowels.  For  if  the 
skin's  action  be  sluo-^ish,  or  the  alvine  evacuations  deficient  in 
quantity,  the  patient  becomes  heated,  and  the  articular  symp- 
toms are  aggravated  in  consequence.  A  very  slight  purgative 
is  usually  sufficient  to  maintain  regularity  of  the  bowels,  and 
nothing  answers  better  than  an  occasional  pill  composed  of 
soap,  ipecacuanha,  rhubarb,  and  aloes,  with  now  and  then  the 
addition  of  a  small  dose  of  colchicum.' 

1  The  following  are  pills  I  frequently  employ,  and  have  found  exceedingly 
useful : 

Ipecacuanhae,  gr.  jss;  Or,  Ipecacuanha?,  gr.  jss  ; 

Saponis  Castiliensis,  gr.  iv  ;  Pilula;  Hydrarg.,  gr.  j  ; 

Pil.  Rhei  Co.,  gr.  iij  ;  Pilulio  Rhci  Co.,  gr.  iij  ; 

Ext.  Aloes  Aquosi,  gr.  j.  M.  ft.  Ext.  Colchici  Acet.,  gr.  ij.  M.  ft. 

Pilulae  ij,  quarum  suiaantur  j,  Pilulae  duae,  quarum  sumantur  j, 

vel  ij,  hord  somni.  vel  ij,  horA  somni. 


318  RHEUMATIC   GOUT. 

There  are  other  remedies,  however,  which  may  be  resorted 
to  with  a  fair  prospect  of  success,  even  when  all  ordinary  med- 
icines have  failed ;  among  which  I  may'mention  an  infusion  of 
the  leaves  of  the  Fraxinus  excelsior.  Few  remedies  have  been 
more  highly  praised  by  those  who  have  had  recourse  to  its  as- 
sistance, and  few  certainly  are  less  known,  or  less  generally 
employed.  Indeed,  in  England  its  antirheumatic  properties 
are  so  little  known,  that  I  have  searched  our  medical  literature 
in  vain  for  the  record  of  a  single  case  in  which  its  remedial 
powers  have  been  tested.  This  is  the  more  remarkable  because 
it  has  been  a  favorite  remedy  with  the  peasants  of  Auvergne, 
and  other  parts  of  France,  for  above  half  a  century,  and  for 
some  years  past  has  attracted  the  attention  of  the  Profession 
on  the  Continent.  So  long  ago  as  the  year  1852,  Messrs. 
Pouget  and  Peyraud  published  a  very  interesting  account  of  its 
curative  virtues.^  These  gentlemen  assert,  as  the  result  of 
their  experience,  that  "  the  infusion  of  the  leaves  is  perhaps  a 
true  specific,  combining  with  the  most  powerful  curative  action, 
the  advantage  of  not  giving  rise  to  any  of  the  dangers  or  in- 
conveniencies  which  result  from  the  use  of  colchicum."  "It 
causes  neither  nausea,  sickness,  general  discomfort,  nor  depres- 
sion," but  "generally  at  the  end  of  four  or  five  days,  and  sometimes 
sooner,  the  pain,  redness,  and  swelling  have  sensibly  diminished 
in  intensity,  or  have  even  disappeared."  In  muscular  rheu- 
matism and  in  other  forms  of  the  disease  it  is  also  spoken  of  as 
an  excellent  remedy. 

My  own  experience  does  not  warrant  my  speaking  in  such 
unqualified  terms  of  its  curative  powers,  but  it  does  justify  my 
stating  that  some  cases  are  greatly  benefited  by  its  agency.  I 
have  already  met  with  several  instances  in  which  the  disease, 
after  resisting  ordinary  remedies,  has  yielded  to  an  infusion 
made  with  one  ounce  and  a  half  or  two  ounces  of  the  leaves  to 
half  a  pint  of  water,  combined  witli  such  other  medicines  as  the 
peculiar  circumstances  of  each  case  demanded.  Moreover,  the 
patients  who  are  most  benefited  by  its  administration  are  the 
very  persons  on  whom  colchicum  is  almost  useless  on  account 
1  See  the  '■  Union  Medicale,"  Nov.  27,  1852. 


TREATMENT    OF    THE    CHRONIC    FORM.  319 

of  its  depressing  or  purgative  action.  Thus  its  remedial 
action  has  been  displayed  most  strikingly  in  persons  already 
exhausted  by  the  disease — in  persons  with  a  disordered  condi- 
tion of  the  stomach,  liver,  and  bowels,  subject  to  profuse, 
clammy  perspiration  on  the  slightest  exertion  ;  whose  urine  is 
at  one  time  scanty  and  turbid,  at  another  abundant,  pale,  and 
of  low  specific  gravity.  In  such  persons,  it  appears  to  stimulate 
the  whole  secreting  apparatus,  and  to  give  tone  to  the  digestive 
organs ;  it  invigorates  the  system  and  checks  the  enfeebling 
sweats;  and  certainly,  in  .some  instances,  is  productive  of 
effects  which  are  sought  in  vain  from  quinine  and  other  bitters. 

At  present,  my  own  experience  of  its  administration  is  not 
sufficiently  extended  to  enable  me  to  speak  with  confidence  as 
to  its  modus  ojyerandi.  In  some  few  instances  I  have  given  it 
uncombined  with  other  remedies,  and  have  been  unable  to  per- 
ceive any  effect  from  its  exhibition  beyond  that  of  gradual  im- 
provement of  the  health,  and  abatement  of  the  pain  and  swell- 
ing. Occasionally,  it  has  given  rise  to  some  slight  temporary 
relaxation  of  the  bowels,  but  more  generally  it  has  proved 
without  purgative  action,  and  has  not  appeared  to  exercise  any 
decided  influence  over  the  secretion  of  the  kidneys.  Indeed, 
its  curative  effects  have  been  displayed  at  times  when  I  was 
able  to  perceive  so  little  real  alteration  in  the  condition  of  the 
excretions,  that  I  have  been  led  to  regard  its  efficacy  as  de- 
pendent on  a  specific  alterative  influence  exerted  over  the  pro- 
cess of  assimilation.  Just  as  colchicum  exerts  what  may  be 
termed  a  specific  curative  action,  quite  independently  of  its 
action  as  a  sedative  or  eliminative,  so  also,  I  believe,  does  the 
Fraxinus  excelsior,  quite  independently  of  its  action  as  a  tonic. 
But  let  the  explanation  of  its  mysterious  agency  be  what  it 
may,  the  fact  remains  that,  administered  with  due  regard  to 
the  condition  of  the  patient,  the  infusion  of  the  leaves  proves 
a  valuable  remedy  in  certain  cases  of  rheumatic  gout,  and  in 
those  especially  which  are  characterized  by  want  of  tone  in  the 
system,  and  by  an  inordinate  and  unhealthy  action  of  the 
skin. 

In  strong  contrast  with  the  action  of  the  remedy  whose  vir- 


320  RHEUMATIC    GOUT. 

tues  we  have  just  discussed,  stands  that  of  another  medicine 
which  proves  a  faithful  ally  in  many  obstinate  cases  of  rheu- 
matic gout.  I  allude  to  arsenic.  It  must  have  been  within 
the  experience  of  every  medical  man  to  meet  with  instances  of 
rheumatic  gout  marked  by  extreme  inactivity  of  the  skin.  The 
patients  referred  to  suffer  greatly  from  cold,  and  rarely,  if  ever, 
perspire,  however  warmly  they  may  be  clad,  however  active  the 
exercise  they  take,  and  however  great  the  heat  to  which  they 
may  be  subjected.  Such  cases  are  always  more  than  usually 
obstinate,  and  are  thoroughly  intractable  to  ordinary  remedies. 
Now  in  these  instances  arsenic  will  often  furnish  the  requisite 
stimulus  to  the  system.  Whatever  its  precise  mode  of  action, 
whether  by  rousing  the  activity  of  the  capillary  system,  by  ex- 
citing cutaneous  exhalation,  or  by  imparting  fresh  tone  and 
vigor  to  the  nervous  system,  and  thus  indirectly  improving  as- 
similation, most  certain  it  is  that  in  a  large  proportion  of  the 
cases  referred  to,  improvement  is  manifested  from  the  very  date 
of  its  administration.  The  languor  and  depression  which  char- 
acterize the  disease  pass  off;  the  complexion  improves;  the 
skin  loses  its  dryness  and  harshness;  the  excretions  reassume 
their  healthy  character ;  the  patient  gains  flesh,  and  the  rheu- 
matic or  gouty  sj'mptoms  subside.  Therefore,  not  unfrequently 
when  other  remedies  have  failed,  I  liave  had  recourse  to  its  as- 
sistance, and  although  in  some  instances  it  has  not  fully  rea- 
lized my  expectations,  I  have  never  had  reason  to  regret  its 
administration.  Given  in  moderate  doses  immediately  after 
meals,  it  rarely  produces  the  slightest  discomfort,  and  even 
when  it  does  give  rise  to  temporary  nausea,  all  unpleasantness 
may  be  got  rid  of  by  suspending  its  administration,  and  then 
diminishing  the  dose.  If  the  urine  be  turbid,  I  usually  pre- 
scribe from  eight  to  fifteen  minims  of  the  liquor  potassee 
arsenitis  in  combination  with  the  acetate  and  bicarbonate  of 
potash,  whereas  if  the  urine  be  clear  and  of  low  specific  gravity, 
or  if  the  mineral  acids  bo  indicated,  I  order  from  ten  to  twenty 
drops  of  the  liquor  arsenici  chloridi,  either  alone  or  in  combi- 
nation with  bark  and  hydrochloric  acid.  By  thus  varying  the 
form  in  which  it  is  given,  according  to  the  different  circum- 


TREATMENT    OF   THE   CHRONIC    FORM.  321 

stances  of  tlie  case,  by  watching  the  patient  carefully  during 
the  period  of  its  administration,  and  by  jealously  guarding 
against  constipation,  not  only  may  this  medicine  be  employed 
with  a  fair  prospect  of  affording  relief  which  would  be  other- 
wise unattainable,  but  the  patient  may  be  securely  guarded 
against  the  disagreeable  effects  which  are  caused  by  its  action 
when  it  is  given  incautiously  or  improperly. 

Unlike  many  other  remedies  which  prove  useful  in  certain 
cases  of  rheumatic  gout,  arsenic  speedily  influences  the  system, 
and  I  have  rarely  met  with  an  instance  in  which  improvement 
has  resulted  from  its  administration  if  some  symptom  of  amend- 
ment has  not  been  manifested  within  a  fortnight  or  three  weeks 
from  the  date  of  its  first  exhibition.  Indeed,  the  only  excep- 
tions to  this  rule  have  been  eases  in  which,  from  the  peculiar 
circumstances  attending  them,  it  was  deemed  inexpedient  to 
begin  by  giving  more  than  a  very  small  dose  of  the  remedy — 
a  dose  insufficient  to  produce  a  speedy  result.  This  of  itself  is 
a  great  encouragement  to  the  physician  to  test  its  remedial 
power  in  obstinate  cases  which  seem  likely  to  be  benefited  by 
its  action,  and  from  the  marvelous  effects  which  I  have  wit- 
nessed as  a  result  of  its  exhibition,  I  feel  justified  in  stating 
that  no  case  of  rheumatic  gout  can  be  regarded  as  incurable, 
on  which  its  influence  has  not  been  fairly  tried. ^ 

Another  remedy  which  I  am  unwilling  to  pass  by  without  a 
brief  notice,  is  the  Arnica  Montana,  or  Leopard's  Bane.  In 
Germany  and  in  other  parts  of  the  Continent  it  is  extensively 
used  internally,  as  a  stimulant  and  diaphoretic;  and  in  our 
own  country,  as  I  am  informed,  it  occupies  a  conspicuous  place 
in  some  of  the  quack  remedies  for  gout  and  rheumatism.  But 
I  have  been  unable  to  find  any  record  of  its  use  internally  by 

1  While  these  pages  were  passing  through  the  press,  my  attention  has  been 
directed  to  a  remarkable  case  in  point,  recorded  by  Mr.  Watson,  of  Cotting- 
hara,  in  Yorkshire.  The  patient,  a  man  sixty  years  of  age,  had  been  a  martyr 
to  the  complaint  nearly  twenty  years.  Crippled,  helpless,  and  exhausted,  he 
seemed  likely  at  no  distant  period  to  fall  a  victim  to  the  disease.  Within  a 
month  after  the  first  dose  of  the  arsenical  solution,  he  slept  comfortably,  ate 
heartily,  and  was  able  to  walk  to  church,  a  quarter  of  a  mile  distant.  (See 
"Association  Med.  Journ.,"' Jan.  19,  1856.) 


322  RnEUMATIC    GOUT. 

professional  men  in  England,  and,  as  far  as  I  am  aware,  it  hap 
not  been  so  employed  except  by  myself.  I  am  the  more  anx- 
ious therefore  to  give  the  result  of  my  experience  as  to  its 
action. 

The  class  of  cases  in  which  it  has  afforded  me  the  greatest 
assistance  is  that  which  comprises  patients  who  are  feeble  and 
exhausted,  whose  skin  is  cool,  whose  pulse  is  weak  and  slow, 
and  whose  urine  is  of  low  specific  gravity.  Its  operation 
appears  to  be  that  of  a  nervine  stimulant  and  diaphoretic.  It 
increases  the  nervous  force,  rouses  the  circulation,  and  so  pro- 
motes more  perfect  assimilation  and  a  more  healthy  action  of 
the  different  excretory  organs.  To  these  properties,  I  believe, 
it  owes  its  value  as  an  adjunct  to  other  remedies  in  the  class  of 
cases  just  referred  to.  For  the  same  reason  it  fails  to  exercise 
a  beneficial  influence  in  cases  characterized  by  nervous  excita- 
bility, with  a  quick  pulse,  heat  of  skin,  and  turbid  urine.  In 
such  cases  it  is  apt  to  produce  headache,  nausea,  or  even 
vomiting,  wakefulness  at  night,  and  other  symptoms  of  dis- 
turbance of  the  nervous  system.  But  let  its  modus  operandi  be 
what  it  may,  I  have  so  often  observed  marked  benefit  from  its 
administration,  that  I  cannot  doubt  as  to  the  expediency  of 
employing  it  in  appropriate  cases.  Given  in  the  form  of  tinc- 
ture or  infusion,*  in  combination  with  cod-liver  oil,  vegetable 
bitters,  and  alkalies  or  the  mineral  acids,  according  to  the 
nature  of  the  case,  it  often  proves  extremely  serviceable,  and 
produces  effects  which  are  sought  in  vain  from  the  same  class 
of  remedies,  unaided  by  its  stimulating  action. 

There  is  yet  another  class  of  cases,  however,  in  which  none 
of  the  remedies  hitherto  mentioned  are  of  much  avail.  I  allude 
to  those  wdiich  have  arisen  in  sequel  of  syphilis  or  gonorrhoea. 
Such  cases  oftentimes  do  not  occur  until  five  or  six  months 
after  all  primary  venereal  symptoms  have  disappeared  ;  and  so 
unwilling  are  the  patients  to  believe  that  their  former  ailment 
has  any  connection  with  their  present  attack,  that  it  is  some- 

1  Of  the  tincture  in  common  use,  tt^xx  to  T^^xxx  may  be  given  as  a  dose,  or 
from  3iv  tu  51  of  an  infusion  prepared  by  macerating  3^j  o'  the  flowers  or  of 
the  root  in  Oj  of  boiling  water. 


TREATMENT    OF    THE    CHRONIC    FORM.  323 

times  difficult  to  elicit  an  admission  as  to  the  possibility  of  the 
existence  of  a  venereal  taint.  Yet  so  obstinate  do  some  such 
cases  prove  until  appropriate  remedies  are  administered,  and 
so  readily  do  thej  yield  when  the  treatment  is  directed  against 
this  presumed  cause,  that  there  cannot  be  a  doubt  as  to  their 
venereal  origin.  In  all  public  institutions,  cases  of  this  sort 
are  of  frequent  occurrence;  and  I  have  had  reason  to  believe 
that  even  in  private  practice  they  are  more  numerous  than  is 
commonly  supposed.  Sometimes,  indeed,  where  mercury  has 
been  taken  freely  for  the  cure-  of  the  original  malady,  and  has 
been  pushed  to  salivation,  the  rheumatic  cachexia  is  connected, 
I  believe,  Avith  the  effect  of  mercury  on  the  system  rather  than 
with  any  remains  of  the  venereal  poison  ;  and  in  such  instances 
I  have  usually  found  that  bark  and  sarsaparilla,  combined  with 
full  doses  (gr.  v  to  x)  of  iodide  of  potassium,  and  aided  in  their 
action  by  an  occasional  vapor  bath,  have  sufficed  to  eradicate 
the  disease ;  but  where,  as  not  unfrequently  happens,  the  pri- 
mary syphilitic  sores  have  been  followed  by  ulceration  of  the 
throat,  cutaneous  eruptions,  or  other  secondary  symptoms,  I 
have  found  nothing  so  useful  in  restoring  health  and  ridding 
the  patient  of  his  rheumatic  gout  as  the  biniodide  of  mercury 
in  combination  with  bark,  the  compound  decoction  of  sarsapa- 
rilla, and  a  generous  diet.  The  same  may  be  said  of  the  disease 
as  it  occurs  in  sequel  of  gonorrhoea.  The  iodide  of  potassium, 
though  often  jiseful  when  administered  in  full  doses,  seems  in 
these  cases  insufficient  of  itself  to  arrest  the  mischief,  but  when 
given  in  conjunction  with  a  drachm  and  a  half  or  two  drachms 
of  the  liquor  hydrargyri  bichloridi  it  speedily  produces  a  bene- 
ficial result.  Case  after  case  has  come  under  my  care  at  St. 
George's  Hospital  in  which  the  combined  influence  of  iodine 
and  mercury  has  arrested  the  disease,  after  it  had  long  with- 
stood the  action  of  these  remedies  exhibited  separately. 

As  soon  as  the  disease  has  yielded,  and  general  debility  only 
remains,  nothing  proves  more  useful  than  a  combination  of 
iodide  of  potassium  with  the  syrup  of  iodide  of  quinine  and  iron  ; 
and  this  or  some  other  form  of  tonic  should  be  taken  for  some 
weeks  after  all  pain  has  subsided,  with  the  view  of  guarding 
against  the  recurrence  of  the  disease. 


824  RHEUMATIC    GOUT. 

Thus,  then,  while  attending  to  the  condition  of  the  internal 
organs,  the  practitioner  should  administer  one  or  more  of  the 
remedies  already  mentioned,  according  to  the  varying  circum- 
stances of  the  case.  But  he  should  not  neglect  to  provide  in 
other  ways  for  the  relief  of  the  local  symptoms  and  the  elimi- 
nation of  the  poison  which  has  heen  already  generated.  He 
should  call  to  his  aid  such  external  applications  as  have  the 
power  of  lulling  pain  and  maintaining  warmth  in  the  affected 
parts,  of  exciting  free  cutaneous  action,  and  of  promoting  the 
absorption  of  any  matters  which  may  have  been  effused.  The 
first-named  indication  may  be  readily  fulfilled  by  employing 
the  opiate  and  alkaline  fomentation,  mentioned  in  the  chapter 
on  the  treatment  of  acute  rheumatism.^  If  the  joints  be  wrapt 
up  in  flannel  saturated  by  the  aforesaid  solution,  a  genial  glow 
and  perspiration  are  induced,  and  the  pain  is  speedily  relieved. 
Even  if  there  be  no  local  redness  or  swelling,  it  is  desirable  to 
clothe  thickly  with  cotton  wool  all  parts  in  which  pain  or  un- 
easiness is  felt.  By  this  simple  expedient  much  unnecessary 
suffering  is  prevented,  and  the  patient,  thus  enabled  to  sleep 
without  having  recourse  to  opiates,  escapes  the  wear  and  tear 
which  inevitably  result  from  long-continued  pain,  and  is  placed 
in  a  position  to  profit  by  any  measures  calculated  to  invigorate 
the  constitution  and  restore  a  healthy  state  of  assimilation. 

Sometimes,  even  when  these  expedients  fail,  relief  is  afforded 
by  the  topical  application  of  a  leaf  of  tobacco.  Care  should  be 
taken  in  selecting  a  fine  leaf  of  true  Virginian  tobacco  :  its 
main  ribs  or  fibers  should  be  taken  out  in  order  that  the  leaf 
itself  may  fit  close  to  the  skin,  and  then,  after  being  steeped 
in  or  moistened  with  hot  water,  it  should  be  placed  round  the 
joint,  and  covered  with  oiled  silk  or  thin  gutta-percha.  On 
several  occasions  I  have  known  this  application  afford  speedy 
relief. 

Among  other  expedients  for  promoting  the  restoration  of 
health,  may  be  mentioned,  the  constant  use  of  friction,  and  full 
daily  ablutions.  Those  who  are  subject  to  rheumatism  are  well 
aware  of  this  important  fact,  and  rarely  fail  to  maintain,  by 

1  See  p.  119. 


TREATMENT    OF    THE    CHRONIC    FORM.  325 

means  of  the  flesh  brush,  that  unobstructed  condition  of  the 
skin's  pores  which  is  essential  to  free  cutaneous  transpiration, 
and  so  to  the  elimination  of  the  morbific  matter.  Nothing, 
indeed,  proves  more  conducive  to  the  cure  of  rheumatism  or 
rheumatic  gout,  which  has  passed  into  a  chronic  and  inactive 
form. 

But  there  are  some  local  consequences  of  the  disease,  for  the 
relief  of  which  the  measures  just  alluded  to  prove  utterly 
inefficient.  After  all  local  symptoms  of  inflammation  have 
subsided,  and  the  swellings  have  in  most  parts  disappeared, 
there  oftentimes  remains  some  thickening  about  the  joints,  or 
an  effusion  into  the  capsules,  the  bursse,  or  the  sheaths  of  ten- 
dons, which  resists  all  ordinary  attempts  to  produce  its  absorp- 
tion. Sometimes  the  knee-joint  is  the  refractory  part,  and  if 
80,  repeated  blistering,  followed  by  the  application  of  mercurial 
ointment  to  the  blistered  surface,'  proves  an  effectual  method 
of  stimulating  the  absorbents  and  getting  rid  of  the  obnoxious 
secretion.  But  sometimes  these  measures  fail  in  their  effect, 
and  it  frequently  happens  that  some  of  the  small  joints  of  the 
fingers  to  which  blisters  cannot  be  readily  applied,  or  the 
sheaths  of  tendons,  or  the  bursas  in  the  immediate  vicinity  of 
the  joints,  are  the  parts  which  call  for  remedial  intervention, 
and  then  it  is  usually  expedient,  if  not  necessary,  to  have  re- 
course to  some  other  mode  of  relief.  In  such  cases  liniments 
and  embrocations-  have  been  recommended,  and,  in  some 
instances,  considerable  benefit  has  been  derived  from  those  of 
a  terebinthinate  and  oleaginous  nature.  But,  generally,  such 
applications  possess  little  virtue  beyond  that  which  attaches  to 
them  in  consequence  of  the  friction  which  accompanies  their 
use  ;  and  far  greafer  benefit  will  be  usually  obtained  from  the 
local  ap])lieation  of  iodine  to  the  affected  joints,  than  from  the 
whole  of  this  class  of  remedies.     The  usual  practice  has  been 

1  "  The  doctrine  of  a  preliminary  constitutional  affection  being  absolutely 
necessary  in  order  to  obtain  the  specific  action  of  mercury  on  any  particular 
organ,  is  wholly  untenable  ;  while,  on  the  other  hand,  there  is  a  host  of  evi- 
dence to  prove  that  locally  applied  it  produces  a  primary  and  distinct  effect, 
totally  independent  of  its  action  oa  the  general  economy."  (Dr.  Graves's 
"  Clinical  Medicine,'"  ed.  2,  vol.  i,  p    490.) 


826  RHEUMATIC   GOUT. 

to  paint  the  affected  parts  with  the  compound  tincture  of  iodine, 
or  even  with  a  stronger  application,  consisting  of  a  drachm  of 
iodine,  and  a  drachm  and  a  half  of  iodide  of  potassium,  dis- 
solved in  an  ounce  of  rectified  spirit,  daily  or  twice  a  day  if  the 
skin  will  bear  it,  until  the  effused  fluid  is  entirely  absorbed.  But 
these  lotions  generally  produce  smarting  and  desquamation  of 
the  cuticle,  and  not  unfrcquently  vesication  after  the  second  or 
third  application  ;  so  that,  although  they  may  prove  useful  as 
counter-irritants,  they  cannot  be  of  any  service  as  absorbents. 
Some  persons,  therefore,  have  preferred  the  iodide  of  potassium 
ointment,  or  cod-liver  oil  containing  iodine  in  solution,  both  of 
which  arc  far  less  irritating  in  their  nature.  But  the  most 
useful  form  in  which  iodine  can  be  applied,  and  one  which  I 
would  strongly  recommend  to  the  Profession,  is  in  very  weak 
solution,  combined  with  glycerin,  to  prevent  its  drying.^  The 
advantages  which  this  possesses  over  all  other  applications  are, 
that  it  does  not  irritate  the  skin,  if  due  precaution  be  observed 
in  its  employment ;  that  it  may  be  applied  without  intermission 
for  weeks,  or  even  months,  if  necessary  ;  that  it  is  readily 
absorbed,  and  produces  the  specific  topical  action  of  iodine, 
without  uneasiness  or  inconvenience  to  the  patient;  and  that, 
as  the  glycerin  prevents  its  drying,  the  lint  or  rag  on  which 
it  is  applied  need  be  wetted  only  once  in  the  twenty-four  hours. 
By  the  aid  of  this  lotion,  with  the  addition  occasionally  of  a  few 
grains  of  bichloride  of  mercury,  forming  a  soluble  biniodide,  I 
have  been  often  enabled  to  reduce  swellings  of  the  joints,  which 
for  months  had  resisted  every  other  plan  of  treatment;  and  on 
several  occasions  have  had  the  satisfaction  of  restoring  the  use 
of  limbs  which  had  been  pronounced  hopelessly  crippled  by 
competent  medical  authorities.*  • 

^  Subjoined  is  the  form  of  lotion  I  usually  employ : 

Tincturae  lodinii  Composite,  5''j~3^j- 
Glycerin),  §iiiss ; 
Aqua;  Desiillatse,  ^iv. 
M.  ft.      Lotio. 
To  this  I  often    add  Hydrargyri    Bichloridi,  gr.    iv-vj,  forming  a  soluble 
Biniodide  of  Mercury. 

2  For  a  remarkable  case  in  point,  see  case  of  George  Wood,  in  "  Hospital 
Case  Book''  No.  2,  for  Nov..  1857,  p.  14.5.  This  man  contracted  the  disease  ia 
ladia,  and  had  been  discharged  from  the  army  as  incurable. 


TREATMENT    OF   THE    CHRONIC    FORM.  327 

Another  very  useful  application,  more  especially  when  the 
smaller  joints  are  principally  implicated,  is  an  ointment  con- 
taining a  drachm  of  calomel,  or  from  four  to  six  grains  of  the 
bichloride  of  mercury,  and  two  drachms  of  iodide  of  potassium, 
to  an  ounce  of  lard.  In  several  cases  I  have  seen  the  thicken- 
ing and  enlargement  yield  to  these  remedies  steadily  perse- 
vered in,  after  having  long  withstood  the  action  of  iodine 
uncombined  with  mercury.  In  some  instances,  however, 
greater  benefit  is  derived  from  the  application  of  the  emplast. 
araraoniaci  c.  hydrargyro,  or-  soap  plaster  with  iodine,  than 
from  the  ointments  just  referred  to. 

When  the  larger  joints  have  been  affected,  and  thickening 
and  stiffness  remain  after  the  more  fluid  parts  of  the  effusion 
have  been  absorbed,  a  different  mode  of  treatment  is  often- 
times necessary.  The  parts  no  longer  require  the  powerfully 
absorbent  influence  of  iodine  or  mercury,  but  they  need  the 
stimulating  action  of  friction  combined  with  the  relaxing  and 
deobstruent  effect  of  local  warmth  and  perspiration.  In  some 
instances,  the  cold  douche,  followed  by  friction,  and  subse- 
quently by  the  wet  bandage,  proves  the  most  effectual  method 
of  restoring  motion  to  the  joint ;  in  others,  douches  of  steam 
or  hot  water,  followed  by  the  wet  bandage  or  warm  fomenta- 
tions, frequent  inunction  with  some  bland  oil,  or  better  still, 
with  cod-liver  oil  holding  iodine  in  solution,  repeated  daily 
rubbing,  the  warmth,  support,  and  gently  stimulating  influence 
of  various  plasters,  and  the  use  of  galvanism,  are  the  means 
best  calculated  to  effect  the  desired  object. 

But  sometimes,  in  addition  to  enlargement  and  stiffness,  there 
exists  some  actual  contraction  of  the  limbs.  It  then  becomes 
necessary  to  adopt  some  means  not  only  to  relieve  the  joint, 
but  to  loosen  the  ligaments  and  set  free  the  tendons  on  which 
the  contraction  of  the  limb  depends.  For  this  purpose  forcible 
yet  gently  applied  extension  of  the  limb  must  be  employed.  If 
at  an  early  stage  of  the  complaint  this  precaution  is  observed, 
all  permanent  contraction  may  be  surely  prevented,  and  even 
at  a  later  stage,  when  the  contracted  tendons  seem  almost  to 
require  the  surgeon's  knife  for  their  relief,  a  judicious  combi- 


32S  RHEUMATIC    GOUT, 

nation  of  local  bathing,  with  manual  friction  and  frequently 
repeated  extension  of  the  limb,  will  often  render  operative 
interference  needless.  Bj  means  such  as  these,  I  have  been 
enabled  on  several  occasions  to  get  rid  of  contractions  of  some 
years'  standing ;  and  it  is  by  these  or  ver^'  similar  measures, 
that  certain  irregular  practitioners  in  this  country  and  on  the 
Continent  have  acquired  a  reputation  for  the  cure  of  enlarged 
and  contracted  rheumatic  joints.  In  all  cases  time  is  an  essen- 
tial element  in  the  production  of  a  favorable  issue  ;  no  change 
will  be  manifest  for  many  weeks, — it  may  be  for  two  or  three 
months  after  a  course  of  treatment  is  commenced;  and  even 
when  the  stiffness  begins  to  yield,  the  progress  toward  cure 
will  not  be  rapid.  Therefore,  before  undertaking  the  manage- 
ment of  such  a  form  of  disease,  it  is  always  advisable  to  explain 
the  circumstances  fully  to  the  patient,  in  order  that  the  treat- 
ment may  not  be  commenced  unless  he  resolves  to  give  it  a  fair 
trial.  So  fully  has  experience  convinced  me  of  the  inutility  of 
half  measures  on  these  occasions,  that  1  now  make  a  point  of 
refusing  to  take  charge  of  patients  so  afflicted,  if  they  declare 
themselves  unwilling,  or,  from  circumstances,  unable,  to  sub- 
mit to  at  least  a  three  months'  course  of  treatment.  Even  this 
period  will  seldom  suffice  for  a  cure,  and  any  plan  of  treatment, 
however  judicious,  if  persisted  in  only  for  a  shorter  time,  will 
assuredly  fail  in  its  object,  and  not  only  cause  disappointment 
to  the  patient,  but  bring  the  physician  into  unmerited  disre- 
pute. 

One  of  the  simplest  and  most  efficient  methods  of  exerting 
gradual  extension  of  the  limb,  is  by  the  use  of  a  smooth  in- 
clined plane  as  a  leg-rest.  The  apparatus  can  be  made  by  any 
carpenter  or  upholsterer.  It  consists  of  a  piece  of  smooth  or 
polished  mahogany,  or  other  wood,  about  a  yard  in  length,  and 
nine  or  ten  inches  in  diameter,  supported  at  its  lower  extremity 
by  a  piece  of  wood,  or  leg,  of  sufficient  height  to  raise  it  about 
four  inches  from  the  ground,  and  at  its  upper  end  by  a  similar 
piece  of  Avood  of  sufficient  height  to  elevate  its  edge  to  a  level 
with  the  chair  on  which  the  patient  is  seated.  When  the  con- 
tracted limb  is  placed  on  this  inclined  plane,  the  weight  of  the 


GENERAL    RULES    IN    REGARD    TO    DIET,    ETC.  329 

leg  forces  the  heel  downward,  and  thus  produces  gradual 
extension.  The  force  thus  exerted  is  such  that  it  cannot  be 
borne  without  discomfort  for  longer  than  twenty  minutes  or 
half  an  hour  ;  but  if  the  leg-rest  is  resorted  to  for  that  period 
three  or  four  times  in  the  course  of  the  day,  and  manual  fric- 
tion employed  at  the  same  time,  or  immediately  afterward,  a 
marked  change  will  be  observed  in  the  limb  within  the  space  of 
a  month  or  six  weeks.  If  the  stiflfness  and  contraction  be  of 
long  standing;,  the  steam  douche  should  be  used  to  relax  the 
parts  before  the  leg  is  placed  on  the  rest,  and  the  joint,  after 
being  thoroughly  rubbed,  should  be  covered  with  an  iodine 
plaster  or  the  emplasticum  ammoniaci  cum  hydrargyro  spread 
on  wash  leather,  as  in  this  way  as  much  progress  is  made  in  the 
course  of  a  week  as  would  result  in  a  fortnight  without  this 
assistance.  In  one  instance  I  was  enabled  by  these  means, 
persevered  in  for  a  period  of  nine  months,  and  aided  in  their 
effects  by  the  occasional  use  of  stimulating  and  absorbent  em- 
brocations, to  straighten  a  leg  which  had  been  contracted 
during  the  space  of  four  years  and  a  half.  Of  course,  if  bony 
anchylosis,  or  distortion  of  the  knee,  has  taken  place,  success 
cannot  attend  our  efforts,  however  judiciously  directed,  and 
perseveringly  employed ;  but  when,  as  is  usually  the  case,  the 
contraction  depends  upon  simple  gluing  together  of  the  struc- 
tures, external  to  the  joint,  with  thickening  of  the  capsule,  and 
possibly  some  remains  of  effusion  within  its  cavity,  or  into  the 
bursas  external  to  the  joint,  I  see  no  reason  for  despair  as  to 
straightening  the  limb,  however  long  contraction  may  have 
existed. 

One  subject,  and  that  by  no  means  an  unimportant  one,  still 
remains  to  be  noticed.  The  imperfect  condition  of  the  assimi- 
lating function  requires  the  observance  of  the  strictest  rules  of 
diet.  The  food  should  be  wholesome  and  nutritious,  but  not  of 
an  over-stimulating  character,  and  whether  fish,  or  flesh,  or 
fowl  be  taken,  it  should  be  simply  drest,  and  eaten  sparingly 
and  at  regular  hours.  With  it  may  be  taken  some  well-cooked 
vegetable,  though  in  a  very  small  quantity,  as  tending  to  pro- 
mote acetous  fermentation  ;  and  for  the  same  reason  salads  and 
22 


830  RHEUMATIC    GOUT. 

pickles  should  be  avoided,  as  also  beer,  sugar,  and  all  sweets. 
More  specific  injunctions  can  hardly  be  laid  down  axiomati- 
cally ;  but,  as  a  general  rule,  I  would  assert  with  Lord  Bacon, 
"  it  is  a  safer  conclusion  to  say,  '  this  agrccth  not  well  with  me, 
therefore  I  will  not  continue  it;' — than,  'I  find  no  ofi"ense  of 
this,  therefore  I  may  use  it.'  "^ 

The  above,  and  other  similar  cautions  respecting  diet,  are  so 
generally  admitted  as  essential,  that  it  is  unnecessary  to  insist 
on  them  more  strongly.  But  there  is  one  point  on  which  the 
same  general  feeling  does  not  exist,  and  as  I  am  thoroughly 
convinced  of  its  importance,  I  wish  to  draw  special  attention  to 
it.  Tea  and  cofi'ee,  and  water,  are  not  usually  included  among 
the  articles  on  which  the  physician  feels  called  upon  to  give 
specific  injunctions,  or  the  patient  to  exercise  ordinary  common 
sense.  The  sufi'erer  from  rheumatism  and  rheumatic  gout,  who 
denies  himself  every  culinary  luxury  in  the  hope  of  getting  rid 
of  his  troublesome  enemy,  permits  himself  at  dinner  to  drink 
water  to  satiety,  and  at  breakfast  and  tea  to  sip  cup  after  cup 
of  his  favorite  beverage,  until  his  thirst  be  appeased  or  his 
stomach  incapable  of  further  distention.  Now,  although  water, 
coffee,  and  tea  are  not  prejudicial  when  taken  in  moderation, 
yet,  in  large  quantities  they  oppress  tfie  'stomach,  dilute  the 
gastric  juice,  and  exert  a  baneful  influence  on  the  process  of 
digestion.  No  person  in  health  can  long  indulge  in  inordinate 
quantities  of  liquids  at  meal  times  with  impunity,  and  to  per- 
sons whose  digestive  organs  are  impaired,  they  are  little  less 
than  poisons.  They  may  prove  grateful,  or  indeed  useful,  as 
diluents,  if  taken  in  moderate  quantity,  when  the  meal  is  three 
parts  finished,  but  at  an  earlier  period  they  should  be  taken 
very  sparingly,  as  if  taken  freely  they  are  decidedly  prejudicial. 

There  are  many  exceptions,  however,  to  these  rules  respect- 
ing diet,  which  it  is  necessary  to  point  out  clearly,  inasmuch  as 
the  recovery  of  the  patient  may  depend  upon  their  full  and 
practical  recognition.  They  occur  chiefly  among  those  sufferers 
from  rheumatic  gout  who  present  a  clean  tongue,  a  cold  and 
clammy  skin,  and  a  very  feeble  pulse.  In  them,  a  spare  diet 
»  Bacon's  "  Wisdom  of  the  Antients."     "  Essay  on  the  Regimen  of  Health." 


GENERAL    RULES    IN    REGARD    TO    DIET,    ETC.  3-31 

and  abstinence  from  stimulants  would  counteract  all  the  good 
■which  would  accrue  from  the  use  of  medicine.  It  behooves  such 
persons  to  be  cautious  as  to  the  selection  of  their  food,  and 
equally  so  to  masticate  it  thoroughly  ;  but,  unlike  the  dyspeptic 
patients,  with  coated  tongues  and  turbid  urine,  to  whom  the 
former  observations  respecting  diet  apply,  they  need  light, 
nutritious  food  at  shorter  intervals  than  usual,  and  seldom  get 
on  comfortably  without  a  certain  amount  of  sherry,  brandy, 
gin,  or  whisky.  Their  appetite  is  seldom  good,  and  they 
require  beef  tea  or  other  light  nutriment  between  their  regular 
meals,  and  some  amount  of  alcoholic  stimulant  to  rouse  their 
dormant  energies,  and  enable  them  to  digest  their  heavier 
meals.  Even  ale  and  porter  need  not  always  be  prohibited. 
The  test  of  its  being  required  by  the  system  is,  that  while  it  is 
being  taken  the  tongue  continues  clean,  the  urine  clear,  and  the 
skin  cool.  If  any  derangement  of  the  secretions  should  occur, 
the  diet  even  in  these  cases  must  be  altered,  and  the  use  of  the 
stimulants  for  a  time  at  least  discontinued.  Under  all  circum- 
stances, Cicero's  advice  must  be  remembered,  that  "  tantum 
cibi  et  potionis  adhibendum,  ut  reficiantur  vires,  non  oppriman- 
tur."^ 

Above  all  things,  it  is  needful  for  the  sufferer  from  rheumatic 
gout  to  take  exercise  freely  and  regularly — exercise  suited  to 
his  strength  and  condition,  but  always  sufficiently  active  and 
sustained  to  produce  a  free  perspiration.  Nothing  tends  more 
directly  to  the  perfect  oxygenation  of  the  blood,  and  to  the 
furtherance  of  those  actions  on  which  the  ultimate  cure  must 
mainly  depend.  And,  as  the  function  of  the  kidneys  is  almost 
always  impaired,  it  is  most  important  to  maintain  a  regular 
action  of  the  skin,  and  to  guard  against  damp  and  chills,  and 
the  ill  effects  of  atmospheric  vicissitudes,  by  means  of  warm 
clothing.  The  patient  should  be  clad  in  flannel  or  fleecy 
hosiery,  from  head  to  foot,  and,  should  he  perspire  freely  while 
taking  exercise,  he  should  never  neglect,  on  returning  home, 
to  change  his  under-garments,  and  to  make  use  of  friction,  by 
the  flesh-brush  or  coarse  towels. 

1  Cicero  de  Senectute. 


332  RHEUMATIC    GOUT. 

Sometimes,  however,  after  several  attacks,  the  disease,  act- 
ing upon  textures  already  weakened,  appears  to  be  beyond  the 
power  of  ordinary  remedies.  In  spite  of  the  best  directed 
efforts  of  the  physician,  even  when  aided  by  the  greatest  cau- 
tion on  the  part  of  the  patient,  the  stomach  performs  its  func- 
tions feebly  and  irregularly ;  the  appetite  remains  indifferent ; 
the  food  is  imperfectly  assimilated ;  the  skin,  the"  kidneys,  and 
the  liver  continue  sluggish  in  their  action  ;  effete  matters  are 
consequently  retained  in  the  system,  the  joints  become  more 
enlarged  and  distorted,  and  the  general  health  gives  way. 
Under  these  circumstances,  recourse  must  be  had  to  the  various 
thermal  springs  with  which  Nature  has  endowed  both  this 
country  and  the  Continent,  as  if  for  relief  of  the  disease  in 
question.  When  everything  else  fails,  they  not  unfrequently 
afford  extraordinary  and  permanent  relief.  Whatever  the  modus 
opeiandi  of  the  waters,  their  free  use,  both  internally  and 
externally,  exercises  a  beneficial  influence,  which  is  in  vain 
sought  from  medicine  and  bathing  in  other  places.  The  effect 
produced  is  at  once  sedative  and  tonic.  The  pain-worn  sufferer, 
irritable  and  anxious,  repairs  to  the  springs,  unable  to  sleep, 
and  troubled  with  dyspepsia,  connected  with  a  sluggish  condi- 
tion of  the  skin,  liver,  kidneys,  and  bowels.  After  ten  days' 
or  a  fortnight's  trial  of  their  virtues,  he  begins  to  find  himself 
less  irritable,  less  anxious,  and  less  wakeful ;  he  sleeps  more 
soundly,  and  feels  more  refreshed  by  his  sleep  ;  his  digestion 
improves,  the  whole  system  is  invigorated ;  and,  after  a  time, 
the  excretory  organs  act  so  much  more  eflBciently,  that  it  be- 
comes unnecessary  to  have  recourse  to  medicines  for  their 
relief.  Coincidently  with  this  increased  freedom  in  the  various 
channels  by  which  the  excretions  are  carried  out  of  the  system, 
and  with  the  greater  purity  of  blood  which  consequently 
ensues,  there  is  observed  a  decrease  in  the  articular  sj'mptoms, 
which  arise,  as  I  have  shown,  from  a  vitiated  condition  of  the 
circulating  fluid.  There  is  no  fresh  accession  of  pain  or  inflam- 
mation, no  recurrence  of  synovial  effusion,  no  increase  of 
thickening  about  the  joints.  On  the  contrary,  the  enlargement 
gradually  subsides ;  and  by  assistance  of  the  water,  applied  in 


CURATIVE    EFFECTS    OP    THERMAL    SPRINGS.  333 

the  form  of  douche,  whereby  local  friction  is  combined  with 
fomentation,  the  stiffness  disappears,  and  the  patient  to  a  great 
degree  regains  his  former  activity. 

It  might  be  supposed,  that  the  importation  of  the  various 
waters  would  render  a  visit  to  their  source  unnecessary.  But 
such  is  not  the  case.  The  natural  waters  may  be  taken  regu- 
larly at  home,  and  diligent  use  may  be  made  of  baths  contain- 
ing the  same  constituents  in  solution,  but  the  effect  is  far  dif- 
ferent  from  that  observed  during  a  residence  at  the  springs. 
The  vast  importance  of  the  total  change  of  scene,  and  air,  and 
habits,  consequent  on  a  visit  to  the  English  or  continental 
watering-places,  can  hardly  be  over-estimated :  a  new  stimulus 
is  imparted  to  the  system ;  the  organic  functions  receive  an 
impulse  which  cannot  be  communicated  to  them  in  any  other 
way  ;  and  remedies  which  have  proved  unavailing  at  home,  very 
shortly  become  active  agents  for  good.  Indeed,  it  is  a  question 
whether  the  benefit  derived  from  a  visit  to  any  of  the  thermal 
springs  is  not  attributable  almost  as  much  to  this  sort  of  in- 
fluence, as  to  the  medicinal  action  of  the  waters. 

The  only  question,  therefore,  which  arises  in  each  particular 
instance,  is  as  to  the  place  best  calculated  to  promote  the  well- 
being  of  the  patient.  In  this  country  the  waters  of  Bath,  Har- 
rogate, Buxton,  Woodhall,  and  Droitwich ;  abroad  those  of 
Aix-la-Chapelle  and  Bareges  ;  Wiesbaden,  Wildbad,  and  Baden- 
Baden  :  Carlsbad,  Teplitz,  and  Vichy,^  are  among  the  most 
celebrated  and  efficient ;  but,  of  course,  the  physician's  selec- 
tion must  be  determined  by  the  result  of  his  inquiries  into  the 
history  of  each  case.  The  baths  of  Harrogate,  Aix-la-Chapelle, 
and  Bareges  belong  to  the  class  of  sulphurous  waters,  and 
being  more  stimulant  than  the  other  waters  alluded  to,  are 
sometimes  of  service  in  old-standing  atonic  cases,  even  when 
other  springs  have  failed.  The  two  latter  are  peculiarly 
adapted  for  persons  of  a  feeble  circulation,  who  are  invigorated 
by  warmth,  and  suffer  greatly  from  the  effects  of  cold ;  while 
the  first-named  spring  is  suited  for  invalids  to  whom  the  dry 

^  The  temperature  and  composition  of  most  of  these  waters  are  given  in  the 
Table  appended  to  this  chapter.     See  pp.  347-350. 


334  RHEUMATIC    GOUT. 

bracinor  air  which  sweeps  over  the  high  table-land  immediately 
adjoining  Harrogate  is  likely  to  prove  grateful  and  beneficial. 
Judiciously  administered,  and  varied  according  to  the  circum- 
stances of  each  case,  the  sulphurous  waters  in  this  country  and 
on  the  Continent  have  proved  a  source  of  renewed  health  to 
many  a  victim  to  rheumatic  gout.  The  springs  of  Bath,  Wies- 
baden, Baden-Baden,  and  Teplitz  contain  in  solution  a  small 
quantity  of  iron,  and  hence  are  especially  useful  whenever 
there  is  a  deficiency  of  red  globules  in  the  blood.  Those  of 
Carlsbad,  Avhich  also  contain  iron,  prove  eminently  serviceable 
in  atonic  bilious  subjects  whose  livers  are  inactive,  and  whose 
secretions  generally  are  sluggish.  The  waters  of  Vichy  are 
strongly  alkaline,  and  are  most  beneficial  in  cases  characterized 
by  extreme  acidity  of  the  stomach  and  of  the  excretions  ;  while 
those  of  Buxton  and  Wildbad,  which  are  strongly  impregnated 
with  nitrogen  gas,  have  earned  a  well-merited  reputation  in 
cases  marked  by  the  existence  of  wandering  pains,  without  the 
concurrence  of  inflammatory  action, — in  cases  therefore  which 
require  alterative  waters  rather  than  those  of  a  more  stimulat- 
ing nature.  To  persons  whose  skin  requires  stimulating,  and 
who  cannot  bear  the  relaxing  effect  of  the  various  hot  springs, 
the  saline  bath  of  Droitwich  is  particularly  adapted  ;  to  those 
whose  systems  are  tainted  with  the  venereal  poison,  or  are  in- 
jured by  the  administration  of  mercury,  and  to  those  again  who 
are  suffering  from  chronic  enlargement  of  the  bursae  and  effusion 
within  the  capsular  membrane,  the  iodine  and  bromine  springs 
of  Woodhall,  in  Lincolnshire,  are  especially  useful ;  while  those 
of  other  places,  to  which  I  need  not  here  allude,  are  equally 
serviceable  in  a  different  class  of  cases,  when  administered  with 
due  regard  to  the  condition  of  the  patient.  But  observation  has 
convinced  me,  that  the  pallid  victim  to  rheumatic  gout,  who 
suffers  from  cold,  and  is  unable  to  bear  the  stimulant  effect  of 
the  sulphur  waters,  will  usually  experience  more  relief  from  a 
month's  residence  at  Bath,  than  from  a  much  longer  sojourn  at 
any  other  watering-place. 

There  is  one  class  of  cases,  however,  which  prove  extremely 
intractable,  whatever  the  means  adopted  for  their  relief.      They 


OCCASIONAL    CAUSE    OF   ITS    INTRACTABILITY.  335 

are  characterized  by  the  unusual  pallor  of  the  patient,  the  dry- 
ness if  not  harshness  of  his  skin,  the  paleness  and  low  specific 
gravity  of  the  urine,  and  an  utter  want  of  tone  in  the  system. 
In  all  cases  of  rheumatic  gout,  more  especially  when  occurring 
in  a  chronic  form,  the  condition  of  the  urine  is  of  primary 
importance,  as  exhibiting  at  a  glance  an  active  or  a  sluggish 
state  of  those  organs  through  whose  agency  the  elimination  of 
the  materies  morbi  is  in  great  measure  effected,  and  without  a 
due  action  of  Avhich  it  is  difficult  to  conceive  that  a  cure  can  be 
permanent.  In  the  obstinateoases  just  alluded  to,  this  defective 
condition  of  the  urinary  secretion  is  even  more  prominent,  and 
is  sometimes  connected  with  permanent  alteration  of  the  struc- 
ture of  the  kidneys,  which  increases  with  the  progress  of  the 
disease  until  complete  degeneration  of  their  secreting  apparatus 
takes  place. ^  If  the  urine  be  allowed  to  stand  for  some  hours 
in  a  funnel-shaped  glass,  and  the  sediment  which  results  be 
then  examined  under  tlie  microscope,  scales  of  glandular  epi- 
thelium will  be  seen,  containing  an  undue  proportion  of  oil-glob- 
ules and  granular  matter,  and  here  and  there  will  sometimes  be 
observed  a  fibrinous  cast  of  an  uriniferous  tube,  and  some  small 
aggregations  of  amorphous  granular  matter  and  half-broken 
epithelium.  Moreover,  if  the  urine  be  concentrated  by  evap- 
oration— sometimes,  indeed,  without  previous  concentration — 
a  slight  coagulum  of  albumen  will  be  formed  under  the  influ- 
ence of  heat  and  nitric  acid.  After  death,  the  cause  of  this 
abnormal  condition  is  apparent :  the  kidneys  are  found  atro- 
phied, granular  on  their  surface  when  their  capsule  is  peeled 
off,  and  utterly  diseased  in  their  intimate  structure.  Hence 
the  cause  of  their  defective  action  ;  hence,  also,  the  lingering 
chronicity  of  the  disease.  The  only  aid  we  can  rationally 
expect  to  give  a  patient  whose  kidneys  are  thus  diseased,  is  that 
afforded  by  inducing  a  free  action  of  the  skin,  liver,  and  bow- 
els, and  by  regulating  the  amount  and  nature  of  the  food.     By 

1  This  complication  is  of  frequent  occurrence  in  true  Gout,  and  appears  to 
be  dependent  on,  or  intimately  connected  with,  the  causes  which  produce  the 
original  disease:  in  Rheumatic  Gout,  on  the  contrary,  it  is  of  rare  occurrence, 
and  seems  to  be  an  accidental  coincidence,  in  no  way  connected  with  the  mor- 
bid changes  in  which  the  primary  disease  takes  its  origin. 


336  RHEUMATIC   GOUT. 

relieving  the  diseased  organs  of  part  of  their  work  ;  by  stimu- 
lating the  healthy  secreting  apparatus  to  take  on  vicarious 
action,  and  so  to  assist  in  the  elimination  of  the  poison,  as  also 
by  strict  attention  to  diet  and  regimen,  we  may  do  much 
toward  warding  oft'  the  final  catastrophe.  Though  we  cannot 
effect  a  cure  of  the  disease,  we  may  render  our  patient's  suffer- 
ings endurable,  and  enable  him  to  pass  the  remainder  of  his 
life  in  comparative  comfort  to  himself  and  family. 

Hitherto  I  have  made  only  slight  allusion  to  the  various 
complications  which  render  this  complaint  peculiarly  formi- 
dable, and  call  for  immediate  relief.  Nor  do  I  intend  to  enter 
at  any  length  into  the  discussion  of  symptoms  which,  though 
sometimes  arising  in  the  course  of  this  disease,  are  yet  of  fre- 
quent occurrence  under  other  circumstances,  and  do  not  demand 
any  specific  treatment.  Inflammation  of  the  brain  has  been 
met  Avith,  though  rarely,  and  has  occurred  almost  invariably 
coincidently  with  the  subsidence  or  sudden  retrocession  of  the 
articular  symptoms.'  Moreover,  in  almost  every  case  on  record, 
it  has  supervened  after  the  disease  has  been  limited  for  some 
time  to  one  or  two  joints,  and  its  attacks  have  been  confined 
to  persons  in  an  unhealthy  cachectic  condition,  who  have  been 
exhausted  and  rendered  irritable  by  the  long  continuance  of 
the  disease.  Its  symptoms  have  seldom  exhibited  the  same 
activity  as  those  which  ordinarily  accompany  inflammation  of 
the  brain  ;  there' has  seldom  been  much  inflammatory  fever  or 
violent  delirium,  but  the  disease  has  gone  on  rapidly  to  a 
fatal  termination,  w"ith  headache,  incoherence,  strabismus, 
paralysis,  and  symptoms  of  pressure  on  the  nervous  centers. 
Instances  in  point  may  be  found  recorded  in  Sir  Benjamin 
Brodie's  work  "On  Disease  of  the  Joints,"^  in  Dr.  Macleod's 
chapter  on  "  Capsular  Rheumatism,"^  and  in  several  of  the 
medical  periodicals ;  but  as  all  the  cases  are  devoid  of  interest, 

1  Since  the  publication  of  the  first  edition  of  this  work,  I  have  seen  reason 
to  doubt  whether  inflammation  of  the  brain,  or  pleurisy,  is  ever  set  up  as  a 
consequence  of  rheumatic  gout.  I  have  never  met  with  a  case  in  point,  and, 
after  carefully  reconsidering  the  recorded  cases,  ray  impression  is  that  they 
were  all  instances  of  true  gout  or  true  rheumatism. 

*  Ed.  4,  p.  51.  3  Qn  "Rheumatism,' p.  118. 


AFFECTIONS    OF   THE    EAR.  337 

save  only  in  so  far  as  they  serve  to  illustrate  the  reality  and 
danger  of  such  an  occurrence,  I  shall  content  myself  by  refer- 
ring to  the  fact  of  their  having  been  recorded,  and  impressing 
upon  all  those  who  may  have  charge  of  patients  laboring  under 
this  disease,  the  necessity  of  taking  active  and  immediate 
measures  should  headache,  vertigo,  somnolency,  impaired  mem- 
ory, or  any  other  symptoms  appear  to  indicate  commencing 
mischief  within  the  cranium.  Should  such  symptoms  be  accom- 
panied, as  they  usually  are,  by  the  subsidence  or  disappearance 
of  articular  swelling,  it  may  be  worthy  of  consideration,  whether 
by  the  application  of  mustard  poultices  and  blisters,  it  may  not 
be  possible  again  to  attract  the  morbific  agent  to  the  joints, 
and  so  to  avert  the  fatal  consequences  which  must  follow  the 
concentration  of  its  whole  force  upon  the  brain. 

Pleurisy  is  a  more  common,  and  practically,  therefore,  a 
more  important  complication.^  In  some  instances,  where  the 
system  is  low  and  susceptible  of  irritation,  pleuritic  inflamma- 
tion is  readily  excited,  and  often  occurs  without  any  manifest 
decrease  in  the  articular  symptoms.  Frequently,  in  such  cases, 
the  morbid  action  is  limited  in  extent,  and  may  be  easily 
checked  by  ap])ropriate  treatment.  But  in  other  cases  it  arises 
coincidently  with,  and  probably  in  consequence  of  the  sudden 
subsidence  of  the  articular  swelling  ;  and  then  if  the  system  be 
depressed,  it  is  rapid  in  its  progress,  pus-generating  in  its 
character,  and  little  under  the  control  of  medicine.  In  such 
instances  the  whole  virulence  of  the  poison  appears  to  be  con- 
centrated upon  the  inflamed  membrane,  and  the  patient  sinks, 
in  part  from  the  shock,  and  in  part  exhausted  by  the  irritation 
of  the  disease,  and  by  the  oppression  to  the  breathing  which 
results  from  an  accumulation  of  pus  and  serum  in  the  pleural 
cavity. 

Deafness  is  a  complication  which  unfortunately  arises  in  a  large 
proportion  of  patients  who  suff"er  from  rheumatic  gout,  and  proves 
at  once  distressing  to  the  sufferer,  and  extremely  obstinate  in  its 
continuance.  The  small  bones  of  the  ear  become  involved  in  the 
changes  which  have  been  already  traced  in  connection  with  the 

1  See  Note  oq  p.  336  of  this  Treatise. 


338  RHEUMATIC    GOUT. 

articulations  of  the  extremities,  and  distortion  and  loss  of  mo- 
tion result.  Not  unfrequently  the  action  of  the  tensor  tympani 
appears  to  be  interfered  with  early  in  the  attack,  producing 
partial  deafness ;  and  as  soon  as  distortion  of  the  bones  has 
proceeded  beyond  a  certain  point,  and  rigidity  of  their  articu- 
lations has  occurred,  the  muscles  become  utterly  incapable  of 
moving  them,  and  complete  deafness  ensues. 

The  plan  of  treatment  commonly  pursued  in  these  cases  is 
the  application  of  blisters  and  irritating  ointments  behind 
the  ears,  followed  by  mercurial  inunction,  and  the  internal 
administration  of  mercurials  and  alkalies  ;  but  having  known 
this  method  fairly  carried  out  by  experienced  aurists  in  a  large 
number  of  cases,  almost  uniformly  without  success,  I  cannot 
but  doubt  whether  it  exercises  the  slightest  curative  influence. 
My  own  observation  would  rather  lead  me  to  recommend  the 
administration  of  tonics,  cod-liver  oil,  and  remedies  which 
experience  has  proved  to  be  productive  of  relief  to  the  local 
effects  of  the  disease  in  other  parts  of  the  body,  and  at  the 
same  time  to  have  recourse  locally  to  the  absorbent  influence 
of  the  biniodide  of  mercury  ointment  rubbed  in  behind  the 
ears. 

Inflammation  of  the  eye  is  another  complication  of  consid- 
erable importance.  It  occurred  in  11  out  of  the  130  cases  of 
rheumatic  gout  which  were  admitted  into  the  hospital  during 
the  time  I  held  the  office  of  Medical  Registrar,  and  the  eye  has 
suffered  more  or  less  severely  in  14  out  of  198  cases  which  have 
fallen  under  my  own  care  at  the  hospital.^  In  private  prac- 
tice, too,  within  the  last  few  years,  several  gentlemen  have 
consulted  me  for  the  same  train  of  symptoms.     Therefore, 

^  Since  the  above  paragraj)hs  were  published  in  the  first  edition  of  this  work, 
I  have  seen  reason  to  doubt  whether  tiie  affection  is  so  common  as  these  figures 
would  appear  to  indicate,  and  whether  many,  if  not  all,  of  the  cases  in  which  this 
complication  arose  may  not  have  been  cases  of  obscure  gout  or  of  gonorrhoeal 
rheumatism.  This  at  least  is  certain,  that  since  my  attention  has  been  specially 
directed  to  this  question,  I  have  been  enabled  to  trace  a  gouty  or  venereal 
taint  in  every  case  in  which  the  eye  has  been  inflamed  in  connection  with 
presumed  rheumatic  gout.  Nevertheless,  I  have  not  as  yet  obtained  sufficient 
evidence  to  justify  a  positive  opinion  on  the  subject,  and  therefore  have  not 
thought  it  right  to  interfere  with  the  text. 


AFFECTIONS    OF   THE    EYE.  839 

although  inflammation  of  the  eye  is  comparatively  rare  in 
rheumatic  gout,  it  is  sufficiently  common  to  demand  our  serious 
attention. 

Affections  of  the  eye,  in  connection  with  rheumatic  gout,  are 
usually  seen  in  those  who  are  thoroughly  out  of  health  or  ex- 
hausted by  repeated  attacks  of  the  disease.  The  inflammatory 
process  is  not  confined  to  any  particular  part  or  texture  of  the 
eye,  but  often  attacks,  either  together  or  in  succession,  the 
various  coats  of  which  the  eye  is  composed.  The  conjunctiva, 
the  sclerotic,  the  choroid,  and  the  iris  are  all  sometimes  impli- 
cated before  the  disease  is  arrested  ;  but  more  commonly,  if 
the  patient  is  under  medical  treatment,  the  choroid  and  the 
iris  escape  altogether.  Very  generally  the  inflammation  com- 
mences in  the  sclerotic  and  spreads  to  the  conjunctiva,  and 
though  not  very  violent,  continues,  in  spite  of  treatment,  for 
several  days.  Even  when  all  symptoms  of  inflammation  have 
been  subdued,  and  the  eye  has  regained  its  natural  appearance, 
the  morbid  action  is  prone  to  recur  without  any  manifest  exter- 
nal cause.  Rarely,"  however,  unless  grossly  neglected,  does 
the  inflammation  leave  permanent  ill  effects  ;  nor  does  it  require 
the  same  activity  in  its  general  treatment,  nor  the  same  amount 
of  topical  applications  which  would  be  necessary  for  its  relief 
in  ordinary  cases.  In  some  instances  it  may  be  deemed  expe- 
dient to  give  calomel  and  opium,  and  to  apply  a  blister  behind 
the  ear,  or  a  few  leeches  to  the  temples,  but  more  commonly 
opiate  fomentations  to  the  eyes,  with  cold  applications  to  the 
temples,  and  derivatives,  such  as  mustard  poultices  or  mustard 
baths,  to  the  feet;  and  internally,  a  brisk  purgative,  followed 
by  an  alkaline  mixture  containing  colchicum,  will  be  sufficient 
to  effect  our  purpose.  If  the  patient  be  very  low,  calomel 
given  so  as  to  produce  ptyalism  aggravates  rather  than  miti- 
gates the  disease,  and  in  such  cases  the  iodide  of  potassium 
and  cinchona  maybe  employed  beneficially  in  combination  with 
small  doses  of  the  liquor  Ilydrargyri  Bichloridi.  Indeed,  in 
this,  as  in  all  similar  instances,  the  symptoms  must  be  combated 
on  general  principles,  due  regard  being  had  to  the  nature  of 
the  disease  in  connection  with  which  they  have  primarily 
arisen. 


340  RHEUMATIC    GOUT. 

The  following  cases  will  serve  to  illustrate  the  treatment  of 
some  of  the  more  obstinate  forms  of  Rheumatic  Gout. 

Case  I. — On  the  15th  of  November,  1855,  I  was  asked  by 
Mr.  Nussej,  of  Cleveland  Row,  to  meet  him  in  consultation  on 

the  case  of  Miss ,  a  young  lady,  set.    23,  who  for  three 

years  had  been  thoroughly  crippled  by  rheumatic  gout.  One 
of  her  aunts  had  suffered  from  this  complaint,  but  she  had  never 
before  experienced  any  rheumatic  symptoms.  The  attack  had 
come  on  slowly  and  insidiously  while  she  was  apparently  in  the 
enjoyment  of  good  health.  Joint  after  joint  became  enlarged 
and  painful,  until  at  length  there  was  hardly  a  joint  in  her 
body  which  was  not  frightfully  distorted.  Her  spine  was  stiff, 
and  could  not  be  bent  without  much  difficulty.  Her  neck  was 
stiff,  as  were  also  the  shoulders,  so  that  she  was  unable  to  raise 
her  arms  to  her  head  ;  the  elbows,  wrists,  and  both  knees  and 
ankles  were  much  enlarged ;  the  hands  were  distorted,  and  some 
stiffness  existed  in  the  hips.  She  had  been  under  medical 
treatment  throughout,  and  had  consulted  several  physicians, 
who  had  ordered  Colchicum,  Alkalies,  Guaiacum,  Iodide  of 
Potassium,  Sarsaparilla,  Cod-liver  Oil,  Quinine,  and  many 
other  remedies ;  and  for  two  successive  summers  she  had  gone 
to  the  German  baths  in  the  vain  hope  of  obtaining  relief. 

When  I  first  saw  her  she  was  a  perfect  cripple ;  she  could 
not  walk,  and  was  unable  to  get  from  her  bed-room  to  the 
drawing-room  without  going  upon  '•  all-fours."  She  could  not 
rise  from  her  chair  Avithout  a  long  and  painful  struggle.  The 
skin  was  acting  freely,  almost  too  readily,  on  exertion,  and  was 
frequently  covered  with  a  cold,  clammy  perspiration.  Tongue 
coated  ;  bowels  rather  costive  ;  urine  very  scanty,  and  loaded 
with  lithates,  sp.  gr.  1019.  Catamenia  regular,  but  too  pro- 
fuse. She  had  a  fair  appetite,  and  never  suffered  from  indi- 
gestion, but,  as  is  usual  in  such  cases,  she  was  becoming  "  low 
spirited."  Heat  oppressed  her,  and  she  was  always  in  better 
health  in  cold  than  in  hot  weather.  A  pill  containing  two 
grains  and  a  half  of  the  acetous  extract  of  Colchicum,  a  grain 
of  Ipecacuanha,  and  enough  of  the  Ext.  Aloes  Aquosum  to 
regulate  the  bowels,  was  ordered  to  be  taken  every  night,  and 


TREATMENT.  841 

another  pill  containing  two  grains  of  the  Pilula  Hydrargyri 
was  administered  as  occasion  required.  A  draught  containing 
Potassae  Acetatis,  jss,  Potassse  Carb.,  9i,  Potassii  lodidi,  gr. 
iv,  Ext.  Taraxici,  .5ss,  and  Tr.  Cinchonre  co.,  .5Jss,  was  ordered 
to  be  taken  three  times  a  day  with  Olei  Morrhute,  oSS.  Gin 
or  whisky  and  water  was  the  beverage  prescribed  for  dinner, 
and  lemonade  was  also  permitted,  if  she  felt  thirsty  during  the 
day.  A  shower  bath  of  cold  water,  followed  by  prolonged  and 
active  friction  down  the  spine,  was  ordered  to  be  taken  every 
morning,  and  an  absorbent  ointment,  frequently  repeated  fric- 
tion, and  various  mechanical  movements  were  employed  to  get 
rid  of  the  stiffness  and  chronic  enlargement  of  the  joints.  Slow 
mastication  and  other  accessories  of  good  digestion  were  also 
specially  insisted  on. 

In  the  course  of  a  month  some  improvement  began  to  mani- 
fest itself,  and  though  from  time  to  time  some  slight  alteration 
was  made  in  the  medicine,  the  general  plan  of  treatment 
remained  the  same.  The  chief  alteration  which  was  made 
consisted  in  the  substitution  of  a  strong  infusion  of  the  Frax- 
inus  excelsior  for  the  Tincture  of  Cinchona.  Before  the  end 
of  three  months  she  was  able  to  take  a  walk  out  of  doors  for 
half  an  hour,  and  after  a  steady  perseverance  of  five  months 
her  general  health  had  greatly  improved  ;  the  swellings  of  the 
joints  had  almost  wholly  disappeared  ;  the  stiffness  had  greatly 
decreased,  and  she  was  on  the  high  road  to  perfect  recovery. 
I  have  not  seen  her  for  several  months,  but  I  hear  from  Mr. 
Nussey  that  she  has  almost  entirely  recovered  her  usual  health 
and  strength,  though  some  of  the  joints  remain  permanently 
distorted. 


Case  II. — .Jane  Hardy,  a  married  woman,  ?et.  30,  was  ad- 
mitted under  my  care  at  St.  George's  Hospital  on  the  16th  of 
June,  1855,  suffering  from  rheumatic  gout  of  two  years'  dura- 
tion. She  had  been  under  treatment  above  eighteen  months, 
and  had  taken  many  warm  baths,  but  was  not  aware  what  rem- 


342  RHEUMATIC   GOUT. 

edies  had  been  employed  internally.  "When  I  first  saw  her,  she 
was  thin,  pale,  and  cachectic  in  appearance ;  her  feet,  ankles, 
both  wrists,  and  several  of  the  finger  joints  were  enlarged, 
swollen,  and  occasionally  painful ;  the  skin  was  dry,  and  un- 
perspiring  ;  indeed,  if  her  own  account  was  to  be  trusted,  even 
a  hot  bath  did  not  cause  the  slightest  perspiration :  tongue 
somewhat  coated.  Bowels  regular.  Catamenia  regular,  but 
scanty.  Urine  formerly  turbid,  but  now  usually  clear,  and 
rather  scanty,  sp.  gr.  1020 ;  appetite  tolerably  good.  Is  rest- 
less at  night,  and  feels  very  weak  and  low  spirited. 

I  advised  her  to  abstain  from  tea  and  malt  liquor :  to  take 
gin  or  whisky  and  water  at  dinner ;  to  have  recourse  to  a  vapor 
bath  twice  a  week,  and  to  employ  a  cold  douche  daily  for  her 
feet  and  ankles.  An  absorbent  ointment  was  ordered  for  the 
joints,  and  the  following  medicines  were  also  prescribed : 

I^.  Potassii  lodidi,  gr.  v ; 
Liq.  Potassae,  tt^xlv ; 
Tr.  Guaiaci  Ammoniatae,  5J  j 
Baust.  Cinchonaj,  S^ss,  ter  die. 

On  the  14th  of  July,  she  was  very  little,  if  at  all,  improved. 
The  vapor  bath  gave  rise  to  excessive  heat,  fullness  about  the 
head,  and  excitement,  but  did  not  make  her  perspire,  and  the 
skin  remained  just  as  dry  as  before.  The  urine  was  more 
abundant  and  clear,  but  the  other  symptoms  remained  the  same. 
The  following  addition  was  therefore  made  to  the  medicine, 
which  was  ordered  to  be  taken  soon  after  meals,  viz.: 

Liquoris  Potassae  Arsenitis,  it^viij ; 

and  a  cold  shower  bath  was  substituted  for  the  vapor  bath. 

From  this  time  her  improvement  was  very  marked,  and 
steadily  progressive.  The  skin  began  to  perspire  within  three 
days  after  the  first  dose  of  arsenic  had  been  taken,  and  by  the 
10th  of  August,  the  complexion  had  become  clearer,  the  pains 
less  constant  and  severe ;  the  sp.  gr.  of  the  urine  had  in- 
creased to  1026,  and  she  felt  stronger  and  better  in  every 
respect. 

From  the  29th  of  September  until  the  27th  of  October,  the 


TREATMENT.  343 

arsenic  was  omitted  by  way  of  precaution,  but  at  that  date,  as 
the  skin's  action  was  becoming  sluggish,  the  use  of  the  arseni- 
cal solution  was  resumed,  and  continued  until  the  24th  of  No- 
vember, when  I  determined  once  again  to  try  whether  its  dis- 
use would  lead  to  inactivity  of  the  skin.  At  this  time  the  pain 
and  swelling  of  the  joints  of  the  upper  extremities  had  wholly 
disappeared ;  the  knees  were  no  longer  swollen,  and  the  feet 
and  ankles  alone  remained  painful.  She  declared  that  her 
general  health  was  better  than  it  had  been  since  the  commence- 
ment of  the  attack,  and  that  were  it  not  for  the  pain  in  the 
feet,  especially  after  walking,  she  should  consider  herself  quite 
well. 

The  discontinuance  of  the  arsenic  had  a  marked  effect  in 
diminishing  the  amount  of  perspiration,  but  as  the  gkin  still 
continued  moist,  I  did  not  deem  it  necessary  to  have  recourse 
to  it  again  at  present. 

On  the  5th  of  January  she  had  a  slight  feverish  attack  ac- 
companied by  relaxation  of  the  bowels,  and  as  it  was  probably 
attributable  to  the  long-continued  use  of  the  ammoniated 
Tincture  of  Guaiacum,  the  former  draught  was  omitted,  and 
the  following  prescribed : 

^..  Potassii  lodidi,  gr.  v; 
Liquoris  Potassae,  5ss; 
Potassae  Acetatis,  5ss  ; 
Ext.  Sarzae,  ^ss; 
Haustus  Cinchonae,  §jss,  ter  die. 

On  the  19th  of  January,  as  the  skin  action  was  again  be- 
coming sluggish,  the  arsenical  solution  was  added  to  the 
draught,  and  was  persisted  in  until  the  1st  of  March,  when  it 
was  finally  discontinued,  the  skin  having  acted  freely  ever 
since. 

On  the  26th  of  April,  she  was  so  well  that  it  was  no  longer 
necessary  for  her  to  continue  taking  medicine,  and  I  advised 
her  going  into  the  country  for  change  of  air,  with  the  view  of 
thoroughly  re-establishing  her  health. 


344  RHEUMATIC    GOUT. 

Case  III.— On  the  18th  of  October,  1853,  I  was  consulted 
by  Miss  W ,  aet.  21,  who,  at  the  recommendation  of  Mr.  Ne- 
ville, of  Esher,  had  been  brought  to  London  to  be  placed  under 
my  care.  She  had  been  suffering  above  a  year  and  a  half  from 
rheumatic  gout,  which,  though  at  first  confined  to  the  wrist  and 
the  small  joints  of  the  fingers,  had  gradually  extended  the  range 
of  its  attacks,  until  few,  if  any,  of  the  joints  had  escaped. 

When  she  first  applied  to  me  she  was  a  perfect  cripple,  and 
unable  to  raise  her  hand  to  her  head ;  the  shoulders,  elbows, 
and  wrists  were  swollen,  stiff,  and  painful ;  the  small  joints  of 
the  fingers  were  distorted,  the  knees  and  ankles  were  painful, 
and  she  suffered  from  pain  and  stiffness  of  the  neck.  The 
symptoms  first  manifested  themselves  at  a  time  when  she  was 
apparently  in  good  health ;  but  with  the  progress  of  the  dis- 
ease the  general  health  had  failed,  and  she  had  become  thin, 
weak,  dyspeptic,  and  low  spirited.  Her  circulation  was  very 
languid ;  the  extremities  were  almost  always  cold ;  the  pulse 
74,  feeble ;  the  tongue  white  and  coated ;  the  bowels  regular 
in  action,  but  the  motions  often  pale  or  else  dark  colored  and 
offensive :  the  monthly  periods  regular ;  the  urine  scanty, 
turbid,  acid,  sp.  gr.  1018 ;  the  skin  usually  damp,  with  a  cold 
clammy  perspiration. 

She  had  taken  large  quantities  of  iodide  of  potassium,  col- 
chicum,  and  other  remedies,  without  the  slightest  relief,  and 
had  had  a  succession  of  hot  baths  with  the  same  result.  The 
manifest  want  of  tone  in  the  system  led  me  to  recommend  a 
tonic  and  alterative  plan  of  treatment.  A  cold  shower  bath 
was  ordered  to  be  taken  daily,  and  to  be  followed  by  active 
friction  down  the  spine ;  an  absorbent  ointment  was  ordered 
for  the  joints,  and  the  following  medicines  were  prescribed  : 

^.  Ilydrargvri  Chloridi,  gr,  xij ; 

Extract!  Aloes  Aquosi, 

Extracti  Colcliici  Acet.,  aa  3j. 
M.  ft.  Pilulfe  duodecim  quarura  siimatur  una  onini  alterou  noctc. 

Liquoris  Potass.c,  §iss; 

Tinctur.T  Guaiaci  Ammon.,  §ij ; 

Extracti  Sarzaj,  ^iss  ; 

Tinctura^  Ciiichoiiae  co.,  §iij. 
M,  ft.  mistura,  cujus  sumatur  cochlearium  unum  magnum  e  cyatho  aquae 
vinario  ter  die. 


TREATxMENT.  345 

Malt  liquor  and  wine  were  interdicted  ;  a  light  but  generous 
diet  enjoined,  and  gin  or  whisky  and  water  recommended  as  a 
beverage  at  dinner. 

After  eight  weeks'  steady  perseverance  with  this  treatment, 
very  decided  amendment  w^as  manifest.  The  general  health 
was  beginning  to  improve  ;  she  suffered  far  less  from  dyspepsia 
and  depression  of  spirits ;  her  complexion  was  clearer ;  the 
tongue  raoister  and  less  coated ;  the  urine  more  abundant, 
though  still  turbid ;  the  bowels  were  regular,  and  the  motions 
of  a  more  healthy  character ;  the  joints  were  much  less  swollen, 
and,  with  the  exception  of  the  right  wrist,  were  no  longer 
painful. 

On  the  9th  of  December,  1853,  fifteen  grains  of  the  Pil. 
Rhei  c.  were  substituted  for  the  calomel,  and  the  pills  and 
medicine  were  continued  as  before. 

From  this  date  until  the  21st  of  June,  1854,  this  plan  of 
treatment,  with  slight  modifications,  was  steadily  persevered  in. 
By  that  time  she  was  in  good  health  and  spirits,  could  take  a 
long  walk  without  inconvenience,  and  could  dress  and  otherwise 
assist  herself,  though  some  stiffness  of  the  shoulders  still 
remained,  and  the  wrists  occasionally  evinced  symptoms  of 
irritation.  The  urine  was  now  abundant  and  clear  ;  the  bowels 
regular,  the  motions  healthy.  The  pulse,  however,  remained 
weak,  and  she  was  still  somewhat  thin  ;  so  I  ordered  her  to  take, 
twice  a  day,  with  half  an  ounce  of  cod-liver  oil,  a  draught  con- 
taining Potassge  Bicarb.,  9j  ;  Ammonise  Sesquicarb.,  gr.  v  ; 
Tincturae  Quinae,  3j.  At  the  same  time,  active  friction,  with 
stimulant  embrocations  and  absorbent  ointments,  were  pre- 
scribed for  the  shoulders. 

From  this  time  onward  her  progress  was  steady  and  satis- 
factory in  every  respect,  and  so  well  did  she  feel,  that  ere  long 
she  gave  up  physic,  and  went  on  a  visit  to  a  married  sister  at 
Oporto. 


Case  IV. — William  Collins,  set.  39,  a  printer  by  trade,  was 
admitted  a  patient  under  my  care  at  St.  George's  Hospital,  on 
23 


346  RHEUMATIC    GODT. 

the  4th  of  March,  1856.  At  the  age  of  24  he  was  profusely 
salivated  for  the  cure  of  syphilis,  and  had  ever  since  suffered 
more  or  less  from  rheumatic  gout,  principally  affecting  the 
small  joints  of  the  hands,  the  wrists,  and  elbows.  The  disease 
was  at  first  confined  to  the  joints  of  the  fore  and  middle  fingers 
of  the  right  hand,  but  had  gradually  extended  to  other  parts, 
until,  when  he  came  under  my  care,  almost  every  finger  was 
enlarged,  stiff,  and  incapable  of  being  bent.  He  said  that  he 
did  not  experience  much  acute  pain,  but  suffered  constantly 
from  aching  stiffness  of  the  joints,  was  incapable  of  and 
thoroughly  indisposed  for  work,  and  felt  low,  irritable,  and 
restless.  He  was  thin,  and  cachectic  in  appearance  ;  his  tongue 
was  almost  clean  ;  bowels  reported  regular  ;  urine  either  pale 
or  else  scanty  and  turbid ;  appetite  indifferent. 

Steaming  and  friction,  with  absorbent  and  stimulating  appli- 
cations, were  ordered  for  the  joints,  and  the  following  medi- 
cines prescribed : 

^.  Extract!  Colchici  Acet.,  gr.  ij,  omni  nocte. 

Potassii  lodidi,  gr.  vj  ; 

Potassse  Bicarbonatis,  5ss ; 

Potassse  Acetatis,  3j ; 

Olei  Morrhuae,  ^iv ; 

Tnfusi  Calutnba",  j,  ter  die. 

By  the  1st  of  April  a  sensible  improvement  had  taken  place. 
The  joints  were  more  flexible  ;  the  urine  was  more  abundant 
and  clear  ;  there  was  less  aching  in  the  joints  ;  and  he  felt  in 
better  spirits. 

The  medicines  were  therefore  continued. 
By  the  22d  of  April  more  decided  progress  had  been  made. 
He  no  longer  experienced  any  pain  ;  the  joints  were  decidedly 
smaller  and  more  flexible  ;  the  appetite  was  good  ;  and  the 
water  abundant  and  quite  clear.  He  was  still  pale  ;  and  so  the 
following  draught  was  ordered  in  lieu  of  that  he  had  hitherto 
taken : 

^.  Potassii  lodidi,  ar.  vj ; 
Syrupi  Ferri  lodidi,  5j  j 
Olei  Monhute,  3'v ; 
Infusi  Ciilumb;e,  3^'U)  t^i"  "i'^' 
The  pill  was  repeated  as  before. 


TEMPERATURE,    ETC.,    OF   THERMAL    SPRINGS. 


347 


Under  this  treatment  the  general  health  improved,  the  joints 
decreased  in  size  and  became  more  flexible,  and  he  was  enabled 
to  resume  his  occupation  as  a  printer.  On  the  20th  of  May  he 
went  into  the  country,  and  from  that  time  I  lost  sight  of  him. 


Table 


Exhibiting  the  Temperature  and  Constituents  of  various  Thermal  Springs. 


BUXTON  WATER. 

Analysis  by  Dr.  Lyon  Play  fair. 

Water  clear,  sparkling,  inodorous. 

Temperature — 82°  Fahrenheit ;  sp.  gr. 

1-0003. 

Solid  contents  of  a  Gallon  : 

grs. 
Silica  .  .  .     0-666 

Oxide  of  Iron  and  Alumina  .     0-240 
Carbonate  of  Lime  .  .     7-773 

Sulphate  of  Lime      .  .     2-323 

Carbonate  of  Magnesia         .     4-543 
Chloride  of  Magnesium        .     0-114 
"  Sodium     .         .     2-420 

"  Potassium         .     2-500 

Fluorine 

(as  Fluoride  of  Calcium)  trace 
Phosphoric  Acid 

(as  Phosphate  of  Lime)  trace 


20  579 


Gaseous  contents  according  to  Volume: 

Carbonic  Acid           .          .  1-167 

Nitrogen         .            .           .  98-833 

Oxygen           .            .          .  trace 


100-000 

At  the  moment  of  issue  the  water  con- 
tains 206  cubic  inches  of  Nitrogen 
per  gallon. 


WOOD  HALL  SPA. 
Wood  Hall,  near  Horncastle,  Lincoln- 
shire. 
Analysis  by  Mr,  West,  of  Leeds. 
Temperature — 55°  Fahrenheit ;  sp.  gr. 


1016. 

Solid  contents  of  a  Gallon : 

grs. 

Chloride  of  Sodium 

1517-00 

"             Calcium 

27-00 

"             Magnesium 

11-00 

Bicarbonate  of  Soda 

6-00 

Sulphate  of  Soda 

2-00 

Bromine 

8-48 

Iodine 

-50 

1571-98 

Gaseous  contents : 

Nitrogen         .         cub.  in 

:h.     20 

Carbonic  Acid 

.     18 

Carburetted  Hydrogen 

4-50 

Sulphuretted  Hydrogen 

trace 

HARROGATE   WATERS. 

Analysis  by  Professor  Hofmann. 

Old  Sulphur  Well. 

Temperature — 48-2°  Fahrenheit;  sp.  gr. 
1  01113. 


348 


TEMPERATURE,    ETC.,    OF   THERMAL    SPRINGS. 


Grains  of  Saline  constitiic 

its  ma  tfullon: 

Sulphate  of  Lime  . 

•182 

Carbonate  of  Lime 

.     12-365 

Chloride  of  Calcium 

.     81-735 

'•         Macfnesium 

.     55-693 

"         Potassium 

.     64-701 

"         Sodium 

.   866  180 

Sulphide  of  Sodium 

.      15-479 

Silica    . 

•246 

1096-580 

Fluoride  of  Calcium,  Bromide  of  So- 
dium, Iodide  of  Sodium,  Ammonia, 
Carbonateof  Iron,  andorg  anic  mat- 
ter, of  each  a  trace. 

Sulphuretted  Hydrogen  Gas,  26-9  cu- 
bic inches. 


DROITWICH  SALINE  BATH. 
Analysis  by  Mr.  Herapath. 
Solid  contents  of  a  Gallon  : 


Chloride  of  Sodium 

Magnesium 

Sulphate  of  Lime 
"  Alumina 

<'  Soda 

Iodide  of  Sodium 


grs. 

21,761-872 

2-560 

91-120 

14-400 

342-720 

•208 

22,212-880 


BATH  WATERS. 

Analyzed hy  Merck  c^-  Galloway,  in  1848. 

King's  Bath  Spring. 

Temperature— llo°  Fahrenheit; 

sp.  gr.  1-0025. 

Contents  of  an  Imperial  Gallon  : 

Carb.  of  Lime     .     grs.         .     8-820 

"  Magnesia        .         .       -329 

"  Iron       .         .         .     1-071 

Sulphate  of  Lime        .         .  80052 

"  Potassa    .         .     4-642 

"  Soda         .         .  19-229 

Chloride  of  Magnesium        .   14-581 

"  Sodium     .         .12-642 

Silicic  Acid  .         .         .     2-382 


144-018 


BAREGES  WATER. 

Temperature,  about  120°  Fahr. 

Contains : 

Sulphide  of  Sodium. 

Carbonate  of  Soda. 

Sulphate  of  Soda. 

Chloride  of  Sodium. 

Nitrogen. 

Free  Sulphuretted  Hydrogen. 

Animal  Matter. 


Carbonic  Acid,  26-45  cubic  inches. 


AIX-LA-CHAPELLE. 

Analysis  of  the  Kaiserkelle 

(^Source  de  VEmpereur)  by  Liebig. 

Temperature — 131°  Fahrenheit; 
sp.  gr.  1-0034. 

Contains  in  a  Pint,  of  16  oz.  : 
Chloride  of  Sodium  grs 
Carbonate  of  Soda 
Sulphate  of  Soda 
Sulphate  of  Potassa 
Carbonate  of  Lime 

"  Magnesia 

"  Iron 

"  Strontia 

"  Lithia 

Bromide  of  Sodium 
Iodide  of  Sodium 
Sulphuret  of  Sodium 
Silica 
Organic  Matter  . 


20-270 

4-995 

2171 

1-186 

1-217 

•395 

•073 

•001 

•000 

•027 

-004 

-072 

•507 

•577 


31-497 


Gaseous  contents  according  to  Volume 
Absorbed  in  the  Water : 

Nitrogen 

Carbonic  Acid 

Bihidroguret  of  Carbon 

Sulphuretted  Hydrogen 

Oxygen 
Free  and  rising  in  the  water  : 

Nitrogen 

Carbonic  Acid 

Bihidroguret  of  Carbon 

Sulphuretted  Hydrogen 

Oxygen 


9-00 

89-40 

•37 

•00 

1.23 

66-98 

30-89 

•182 

-3' 

•00 


TEMPERATURE,    ETC.,    OF   THERMAL    SPRINGS. 


349 


WIESBADEN  WATER. 
Analysis  by  Fresenius. 
Temperature  of  Kochbruanen 

158°  Fahrenheit. 
Contains  in  a  Pint: 
Chloride  of  Sodium  grs. 
"  Potassium 

"  Lithium 

"  Ammonium 

"  Calcium   . 

"  Magnesium 

Sulphate  of  Lime 
Carbonate  of  Lime     . 
"  Magnesia 

"  Protoxide 

of  Iron 


Water, 


52-497 
1-119 
•001 
•128 
•617 
•566 
•692 
•210 
-079 

-043 


55-952 


With  traces  of  Iodine,  Bromine, 
Arsenic,  Alumina,  Strontia,  Cop- 
per, Manganese,  Bar_)  ta,  Silica,  and 
organic  matter,  bringing  the  solid 
contents  of  a  Pint  up  to  63-457  grs. 

Carbonic  Acid  free  and  com- 
bined with  Carbonates    .       3-903 

Nitrogen    .         .         .         .         -015 


IBADEN-BADEN  WATER. 

Analysis  by  Kastner. 

Temperature  of  Ursprung, 

about 

120°  Fahrenheit. 

A  Pint  contains  : 

Chloride  of  Sodium  grs. 

.   17-500 

"              Calcium    . 

.     1-500 

"             Manganese 

-500 

Sulphate  of  Lime 

.     2-750 

Carbonate  of  Iron 

•111 

22-361 

Free  Carbonic  Acid,  '5  cubic  inches. 

TEPLITZ  WATER. 
Analysis  by  Ambrozzi. 
Temperature — 114°  Fahrenheit. 
A  Pint  contains: 

Sulphate  of  Soda  grs.  .     1-696 

Chloride  of  Sodium      .         .       -776 
Carbonate  or  Soda  .  12-240 


Carbonate  of  Lime 
BiHca  . 
Extractive   . 
Carbonate  of  Iron 


-340 
-420 
•100 
-036 


15-608 


Free  Carbonic  Acid,  2-4  cubic  inches. 


CARLSBAD  WATER. 
Analysis  of  the  Sprudel,  by  Berzelius. 

Temperature — 167°  Fahrenheit. 
Sixteen  Ounces  contain: 

Chloride  of  Sodium  grs.       .     7-975 

Sulphate  of  Soda  .         .   19-869 

Carbonate  of  Soda        .         .     9-695 

"  Lime        .         .   10050 

"  Magnesia         .     1-370 

"  Iron         .         .       -028 

Silica 577 


43-564 


With  traces  of  Manganese,  Strontia, 
Alumina. 

Free  Carb.  Acid,  11*8  cubic  inches. 


WILDBAD  WATER. 
Analysis  by  Siywerth. 
Temperature— ^ii°  Fahrenheit. 
Sixteen  Ounces  contain  : 
Chloride  of  Sodium  grs. 
Sulphate  of  Soda 
Carbonate  of  Soda 
"  Lime 

"  Magnesia 

Sulphate  of  Potash 
Silica 
Oxide  of  Iron 

"  Manganese     . 


1-820 
■400 
-530 
-340 
-070 
-020 
•390 
•020 
•030 


3-610 

Gaseojfs  contents  according  to  Volume: 
Carbonic  Acid  .  .  .  2-00 
0-xygen  ....  650 
Nitrogen      ....     91-50 

10000 


360 


TEMPERATURE,    ETC.,    OF   THERMAL    SPRINGS. 


VICHY  WATEPvS. 

ANALYSIS    BY    MONS.    BOUQUET. 

Contents  of  a  Litre  of  Water  expressed  in  grammes. 


Constituents  of  the  Vichy  Waters. 

Grande 
Grille. 

Hopital. 

C61estins. 

Hauterive. 

Des 
Dames. 

Carbonic  Acid 

Bicarb,  of  Soda 

"        of  Potass ' 

"         of  Magnesia    .... 

"         of  Strontia      .... 

"        of  Lime 

"        of  Protoxide  of  Iron     . 
Bicarb,  of  Protoxide  of  Mungauese 

Sulphate  of  Soda 

Phosphate  of  Soda     .... 
Arseniate  of  Soda       .... 

Borate  of  Soda 

Chloride  of  Sodium    .... 

Silica 

Organic  Matter,  Bituminous     . 

Temperature     .     .     .      i 

0-908 
4  883 
0-352 
0-303 
0-003 
0-434 
0-004 

A  trace 
0-291 
0-130 
0-002 

A  trace 
0-534 
0070 

A  trace 

1-067 
5-029 
0-440 
0-200 
0-005 
0-570 
0-004 

A  trace 
0  291 
0-046 
0-002 

A  trace 
0-518 
0050 

A  trace 

1-299 
4  101 
0-231 
0  554 
0-005 
0-6tj9 
0004 

A  trace 
0-314 

A  trace 
0003 

A  trace 
0-550 
0-065 

A  trace 

2  183 
4-687 
0189 
0-501 
0-003 
0432 
0-017 

A  trace 
0-291 
0-046 
0-002 

A  trace 
0-534 
0-071 

A  trace 

1-908 
4016 
0-189 
0-425 
0-003 
0-604 
0026 

A  trace 
0-250 

A  trace 
0-003 

A  trace 
0-355 
0-032 

A  trace 

7  914 

8-222 

7-865 

8  946 

7-811 

105° 
Fah, 

87° 
Fah. 

55° 
Fah. 

58  to  61° 
Fah. 

cold. 

353 

'  ic  disorder,  and 

''ormer  case 

'~ey  fre- 


CHAPTER  XII. 


ON  CHRONIC  RHEUMATISM. 

When  describing  the  symptoms  of  acute  rheumatism,  I  re- 
marked on  the  difference  of  the  structures  affected  in  different 
cases,  and  pointed  out  the  reasons  which  induced  me  to  chissify 
all  the  varieties  under  one  comprehensive  title.  I  stated  that, 
although  in  some  instances  one  texture  or  one  part  of  the  body 
may  be  principally  if  not  exclusively  affected,  yet  that  much 
more  frequently  the  different  forms  of  the  disease  coexist  to 
some  extent  in  the  same  individual,  or  at  least  pass  rapidly  the 
one  into  the  other,  thus  not  only  asserting  the  identity  of  their 
origin,  but  rendering  a  classification,  founded  simply  on  ana- 
tomical peculiarities,  inconsistent  with  the  pathological  phenom- 
ena. The  same  reasons  may  be  urged  with  equal  propriety 
against  the  distinctions  which  have  been  drawn  between  the 
varieties  of  the  disease  as  they  are  met  with  in  a  chronic  form. 
In  some  instances  the  fibrous  structures  about  the  joints,  in 
some  the  capsular  membrane  lining  the  joints,  in  some  the 
fibrous  envelopes  of  the  nerves,  and  in  others  the  muscles  with 
the  aponeurotic  sheaths,  the  fascite  and  tendons,  or  the  perios- 
teum in  various  parts  of  the  body,  may  be  more  conspicuously 
affected  ;  but  occasionally  one  variety  lapses  into  another,  and 
a  fibrous  rheumatism  may  thus,  after  a  time,  be  complicated  or 
replaced  by  synovial  symptoms,  and  may  ultimately  terminate 
in  sciatica,  or  some  other  form  of  neuralgic  pain,  or  in  rheu- 
matism affecting  the  muscles  only. 

Whether,  then,  in  an  acute  or  chronic  form,  the  disease  is 
always  one  and  the  same,  acknowledging  the  same  origin,  though 
varying  in  its  type  according  to  the  age  and  constitution  of  the 
patient,  the  quantity  of  the  poison  present  in  the  system,  and  a 


352  CHRONIC    RHEUMATISM. 

variety  of  other  modifying  circumstances.^  Whatever  its  pre- 
cise character,  however,  the  acute  may  pass  into  the  chronic 
form,  and  the  chronic  may  light  up  into  an  active  state,  and 
present  the  symptoms  of  the  acute  disorder.  These  are  facts  of 
every-day  experience,  and  receive  constant  illustration  in  the 
wards  of  every  large  hospital.  But,  according  as  the  disease 
is  acute  or  chronic,  a  remarkable  difference  is  usually  observed 
in  the  parts  principally  affected.  Thus,  an  acute  attack  is 
often  ushered  in  by  wandering  pains,  which  are  chiefly  if  not 
wholly  confined  to  the  muscular  structures ;  but  no  sooner  are 
the  acute  symptoms  developed,  than  the  muscular  pains  subside, 
and  the  joints  are  chiefly  if  not  solely  affected.  So,  again, 
when  all  acute  symptoms  have  disappeared,  not  only  does  there 
remain  a  stiffness  or  a  dull  aching  pain  in  the  joints,  but  the 
muscles  in  various  parts  of  the  body  are  often  more  or  less  im- 
plicated. The  patient  suffers  from  pain  and  stiffness  in  the 
shoulders,  or  across  the  loins,  or  finds  himself  unable  to  move 
his  hip,  in  consequence  of  pain  which  he  experiences  in  the 
muscles  whenever  he  attempts  to  do  so.  Thus,  whatever  the 
cause  of  this  peculiarity,  the  fact  of  its  existence  admits  not  of 
doubt.  The  articular  structures  are  the  parts  most  commonly 
affected  in  acute  rheumatism  ;  the  muscles,  their  fasciae  and  ten- 
dons, more  generally  suffer  in  the  chronic  form  of  the  disease. 
The  muscles  may  be,  and  sometimes  are,  implicated  in  the 
acute  disease,  and  the  joints  in  like  manner  are  not  unfre- 
quently  attacked  during  the  chronic  stage  of  the  disorder;  but 
the  distinction  just  alluded  to  holds  good  so  generally,  that  in 
practical  importance  muscular  rheumatism  ranks  far  above  all 
other  forms  of  the  complaint,  as  it  occurs  in  a  chronic  state. 
Chronic  rheumatism,  then,  may  either  be  a  sequel  of  an  acute 

1  In  making  tins  statement,  I  do  not  wish  to  imply  that,  in  all  cases  of  so- 
called  chronic  rheumatism,  the  disease  is  identical  in  its  nature  and  origin  with 
true  rheumatism.  On  the  contrary,  it  is  my  firm  conviction  that  several  distinct 
diseases,  acknowledging  ditt'erent  origins,  and  attributable  to  different  morbid 
poisons,  are  usually  included  under  the  title  of  chronic  rheumatism.  I  only 
wish  it  to  be  understood  that  true  rheumatism  is  the  same  disease,  and  is  trace- 
able to  the  same  source,  whether  it  assumes  an  acute  or  chronic  form,  or  affects 
one  or  other  tissue  of  the  body. 


LUMBAGO.  353 

attack,  or  may  commence  at  once  as  an  idiopathic  disorder,  and 
preserve  its  character  from  first  to  hist.  In  the  former  case 
the  joints  are  rarely  free  from  pain  ;  in  the  latter  they  fre- 
quently escape  altogether.  In  hoth  instances,  however,  the 
disease  is  characterized  by  a  dull  aching  or  uneasiness,  which 
is  aggravated  or  quickened  into  agonizing  pain  by  sudden  mo- 
tion of  the  aifected  parts,  and  subsides  in  some  measure  after 
perfect  rest.  It  is  rarely  accompanied  by  local  heat  or  redness, 
and  seldom  by  oedema  or  by  effusion  into  the  joints ;  and  even 
when  articular  swelling  does  occur,  it  is  unattended  by  active 
febrile  disturbance.  The  boundary  line,  however,  between 
chronic  rheumatism  and  that  more  active  form  of  the  disease 
which,  in  the  severity  of  its  symptoms,  is  intermediate  between 
it  and  acute  rheumatism,  is  often  very  faintly  marked,  and  thus 
it  sometimes  becomes  difficult  to  decide  whether  a  case  should 
be  designated  chronic  rheumatism,  or  whether  it  ought  not 
more  properly  to  be  classed  among  those  which,  as  holding  an 
intermediate  position,  have  been  entitled  cases  of  subacute 
rheumatism,  and  have  been  treated  in  accordance  with  their 
subsiGute  character. 

One  of  the  forms  in  which  chronic  rheumatism  most  fre- 
quently presents  itself  in  practice  is  that  of  lumbago.'  The 
patient  who  has  suffered  perhaps  from  little  else  than  stiffness 
in  various  parts  of  the  body,  is  seized  with  pain  and  aching 
across  the  loins.  So  long  as  he  remains  quiet,  he  enjoys  com- 
parative immunity  from  suffering ;  but  he  undergoes  torture 
whenever,  in  an  unguarded  moment,  he  bends  or  twists  his  body, 
or  forgets  to  observe  due  caution  in  moving.  Is  he  lying  in 
bed  at  the  time  of  his  seizure  ?  he  finds  it  difficult  to  raise  him- 
self into  a  sitting  posture:  is  he  seated  in  a  chair?  he  finds  it 
equally  difficult  to  rise  on  to  his  feet :  and  if  standing  erect,  he 
rarely  finds  it  an  easier  task  to  assume  a  sitting  or  recumbent 
posture.  To  stoop  forward  is  impossible,  so  agonizing  is  the 
pain  induced  in  the  muscles  and  fasciae  of  the  back,  which  are 
thus  called  into  action. 

^  The  terras  "  form  "  and  "  variety  "  are  employed  as  implying  simply  a  dif- 
ference in  the  seat,  and  not  in  the  real  nature,  of  the  disease. 


354 


CHRONIC    RHEUMATISxM. 


When  the  attack  is  severe,  the  unfortunate  sufferer  may  be 
obliged  to  remain  in  bed,  or  to  lie  on  the  sofa,  for  several  succes- 
sive days  ;  and,  in  such  cases,  there  is  usually  some  amount  of 
constitutional  disturbance,  marked  by  a  coated  tongue,  accele- 
ration of  the  pulse,  and  acid,  dark-colored,  or  loaded  urine. 
Even  when  the  attack  is  less  severe,  it  calls  no  less  urgently 
for  relief.  For  although,  in  the  first  instance,  the  general 
health  may  suffer  little,  the  patient  can  never  walk  without 
difficulty,  is  frequently  unable  to  raise  himself  into  an  erect 
position,  and  is  quite  incapacitated  for  the  active  duties  of  life. 
Moreover,  the  disease,  though  not  very  severe,  is  apt  to  be  ex- 
ceedingly obstinate;  and,  if  neglected  at  first,  may  linger  on 
for  weeks  or  months  in  spite  of  any  treatment  which  may  be 
subsequently  adopted. 

Another  most  annoying  form  of  the  disease,  which  is  fre- 
quently induced  by  exposure  to  draughts,  is  that  which  affects 
the  muscles  of  the  neck,  and  constitutes  the  conplaint  which 
is  commonly  known  by  the  appellation  of  a  "stiff"  or  "wry" 
neck.  The  pain  is  much  the  same  as  that  which  characterizes 
lumbago,  and  like  it  is  induced  or  aggravated  by  motion.  At 
first  it  may  yield  readily  to  appropriate  treatment ;  but  some- 
times, when  neglected,  it  continues  obstinately  fixed  in  one 
particular  spot,  and  then  may  give  rise  to  distressing  con- 
sequences. To  relax  the  parts,  and  so  lessen  the  pain  which 
is  caused  by  the  tension  of  the  affected  muscles,  the  patient 
either  holds  his  head  awry,  or  bends  it  toward  the  affected 
side ;  and  while  in  this  position,  so  much  of  the  rigidity  of  the 
muscles  may  ensue  as  to  render  it  difficult  for  him  to  regain 
his  former  posture.  Such  cases  are  rare  ;  and,  in  my  expe- 
rience, have  only  occurred  after  repeated  attacks,  or  where 
the  disease  has  been  grossly  neglected;  but  they  are  sufficient 
to  warn  us  to  lose  no  time  in  hastening  to  our  patient's  relief. 

Another  variety  is  that  which  is  known  as  "intercostal" 
rheumatism.  The  parietes  of  the  chest,  like  other  parts  of  the 
body,  are  liable  to  be  attacked  by  the  rheumatic  poison  ;  and 
like  them  too,  when  attacked,  become  exquisitely  painful. 
Motion  greatly  aggravates  the  pain.     Hence  the  suffering  is 


INTERCOSTAL    RHEUMATISM.  355 

increased  by  the  act  of  inspiration  ;  and  the  "  stitch"  which 
thus  results,  and  which  in  many  respects  resembles  the  stitch 
of  pleurisy,  has  led  to  serious  mistakes  in  practice.  The 
patient  has  been  bled,  and  leeched,  and  blistered,  when  no 
antiphlogistic  remedies  were  required.  But  intercostal  rheu- 
matism may  be  readily  distinguished  from  the  pain  of  pleurisy 
by  the  absence  of  fever,  which  usually  marks  the  invasion  of 
that  disease  ;  by  the  absence  of  cough  and  other  symptoms  of 
pulmonary  irritation ;  by  the  tenderness  which  is  evinced  on 
external  pressure;  by  the  freedom  from  pain  on  pressure 
upward  under  the  short  ribs  ;  by  the  increase  of  pain  which 
results  from  raising  the  arm  above  the  head;  by  the  relief 
afforded  when  the  ribs  are  fixed,  and  the  intercostal  muscles  are 
thus  kept  at  rest  ;  and  by  the  absence  of  those  physical  signs 
of  pleurisy  which  are  obtained  by  percussion,  and  by  the  care- 
ful use  of  the  stethoscope. 

When  the  disease  fixes  itself  for  some  length  of  time  in  any 
particular  part,  as  in  the  muscles  of  the  thigh  or  arm,  it  not 
only  occasions  pain,  but  leads  to  atrophy  and  wasting  of  the 
limb.  It  does  so,  not  by  any  change  induced  in  the  structure 
of  the  parts,  nor  by  any  special  influence  which  it  exerts  over 
their  nutrition,  but  simply  by  occasioning  such  disuse  of  the  mus- 
cles as  naturally  leads  to  their  gradual  attenuation.  Anxious 
to  avoid  the  pain  attendant  upon  any  movement  of  the  affected 
structures,  the  sufferer  learns  to  keep  them  at  rest ;  and  thus, 
after  a  time,  their  nutrition  takes  place  less  actively  and  less 
perfectly,  and  they  waste,  and  become  gradually  weaker  and 
smaller.  In  all  such  cases,  therefore,  though  pain  be  induced 
at  first,  much  benefit  will  ultimately  result  from  moving  and 
exercising  the  affected  limbs,  as  also  from  employing  electricity 
and  friction,  and  submitting  to  that  more  active  process  of 
rubbing  and  kneading  which  is  commonly  known  as  shampooing. 

When  the  structures  which  enter  into  the  formation  of  the 
joints  are  affected  by  chronic  rheumatism,  pain  of  greater  or 
less  intensity  ensues,  and  varies  in  its  character  according  to 
the  nature  of  the  parts  affected.  Very  generally  the  ligaments, 
and  their  fibrous  structures  immediately  surrounding  the  joints, 


356  CHRONIC   RHEUMATISM. 

are  the  parts  principally  if  not  solely  implicated  ;  and  then  the 
old  term  of  "dolor  articulorum"  represents  the  extent  and 
character  of  the  affection.  There  is  neither  swelling,  nor 
heat,  nor  redness,  but  there  is  a  dull  aching  of  the  joints, 
which,  when  roused  and  excited  by  sudden  motion,  is  con- 
verted into  pain  of  a  distressing  kind,  which  sometimes  wears 
off  or  diminishes  in  intensity  after  the  parts  have  been  kept 
some  time  in  exercise. 

When  the  bursae  and  the  synovial  membrane  lining  the  joint 
become  the  seat  of  irritation,  and  effusion  takes  place  into  their 
cavities,  the  pain  is  usually  less  severe  and  less  constantly 
aggravated  by  sudden  motion  ;  but  it  is  more  certainly  increased 
by  continued  exercise,  and  is  most  felt  when  the  limbs  are  in 
those  positions  in  which  the  irritated  membranes  are  put  upon 
the  stretch.  Thus,  when  there  is  effusion  into  the  capsular 
membrane  of  the  knee,  pain  is  sure  to  be  induced  by  full  flexion 
of  the  leg,  and  is  greatly  relieved  by  keeping  the  limb  in  a 
horizontal  position,  and  straight,  or  very  slightly  flexed.  And 
when  the  bursse  and  the  adjoining  tendinous  sheaths  are  the 
seat  of  effusion,  any  action  which  tends  to  bring  the  parts  into 
play  is  certain  to  be  accompanied  by  an  increase  of  suffering. 
The  wrist  is  one  of  the  common  situations  of  these  enlarged 
bursae,  and  excessive  pain  is  sometimes  occasioned  by  long- 
continued  use  of  the  affected  joint  and  of  the  tendons  connected 
with  it.  In  the  chronic  state,  however,  which  I  am  now 
describing,  although  the  swelling  may  be  considerable,  there 
is  no  remarkable  febrile  disturbance,  no  discoloration  of  the 
skin,  and  but  little  if  any  perceptible  increase  of  local  action. 

One  form  of  the  complaint,  which  is  apt  to  prove  extremely 
obstinate,  is  that  which  arises  in  sequel  of  urethral  discharge. 
Generally,  about  the  third  day  of  the  discharge,  the  patient 
feels  chilly,  and  is  seized  with  pain  in  one  or  more  joints, 
accompanied  by  excessive  synovial  effusion,  and  by  inflamma- 
tion of  the  ligaments  and  the  adjoining  bursae  and  sheaths  of 
tendons.  Coincidently  with  the  occurrence  of  articular  mis- 
chief, the  discharge  sometimes  ceases ;  but  more  generally  it 
only  decreases  in  quantity,  and  a  gleety  discharge  continues 


GONORRHEAL   RHEUMATISM.  357 

throughout  the  attack.  At  first  there  may  be  more  or  less 
febrile  disturbance,  but  this  soon  passes  off;  and  though  the 
patient  remains  crippled  by  pain  and  swelling  of  his  joints,  and 
by  exquisite  pain  in  the  tendons  and  fasciae  whenever  he 
attempts  to  move,  yet  his  tongue  is  often  clean,  his  bowels 
regular,  his  urine  clear,  the  pulse  quiet,  the  appetite  good. 
These  peculiarities,  together  with  the  severity  of  the  pains, 
the  obstinacy  of  their  continuance,  and  the  proneness  which  is 
manifested  to  inflammation  of  the  eyes,  constitute  the  chief 
characteristics  of  this  form  of  disease. 

I  have  never  known  this  malady  to  occur  except  in  persons 
who  were  either  suffering  from  urethral  discharge,  or  who — it 
may  be  years  before — had  experienced  an  attack  of  rheumatism 
during  the  existence  of  gonorrhoea.^  But  I  have  so  often  seen 
it  recur  in  such  persons,  coincidently  with  or  shortly  after  the 
appearance  of  a  slight  gleety  discharge,  which,  as  far  as  I 
could  ascertain,  was  excited  solely  by  excessive  sexual  inter- 
course and  an  undue  amount  of  alcoholic  stimulants,  that  I 
cannot  doubt  the  predisposition  which  exists  in  persons  who 
have  once  experienced  an  attack,  to  a  recurrence  of  articular 
symptoms  on  the  slightest  irritation  of  the  urethra. 

Some  persons  have  maintained  that  this  form  of  disease  is 
nothing  more  than  ordinary  rheumatism  excited  in  a  gouty 
habit,  and  they  have  referred  to  the  excessive  synovial  effusion, 
the  frequency  of  inflammation  of  the  eyes,  and  the  constant 
recurrence  of  the  disease  coincidently  with  slight  gleety  urethral 
discharge,  but  without  any  evidence  of  active  gonorrhoea,  in 
support  of  their  position.  My  own  opinion,  however,  is  opposed 
to  this  view.  The  persons  in  whom  it  occurs  are  often  young, 
slim,  and  of  active  habits,  who  have  neither  inherited  a  predis- 
position to  gout,  nor  acquired  the  tendency  by  their  own  mode 
of  living  :  the  big  toe,  which  is  almost  always  affected  in  gout, 
is  rarely  so  in  this  form  of  malady ;   and  colchicum,  which 

1  Though  I  make  use  of  the  term  gonorrhoea  in  connection  with  this  form 
of  rheumatism,  nij'  conviction  is  that  so-called  gonorrheal  rheumatism  arises 
in  connection  witii  a  urethral  discharge,  which  is  essentially  distinct  from  that 
which  accompanies  ordinary  gonorrhoea,  and  is  excited  by  a  peculiar  and  com- 
paratively rare  form  of  vaginal  poison. 


858  CHRONIC    RHEUMATISM 

exerts  a  marked  influence  over  gout,  is  powerless  to  restrain 
the  course  of  this  disease,  or  to  modify  its  intensity.  So  also 
are  the  medicines  ordinarily  given  for  the  cure  of  rheumatism. 
Indeed,  I  feel  persuaded  that  it  has  no  connection  with  true 
gout  or  true  rheumatism,  but  is  a  disease  sui  generis,  engen- 
dered by  a  specific  poison,  and  requiring  a  special  mode  of 
treatment.  • 

There  is  yet  another  form  of  rheumatism  which  is  apt  to 
occur  in  cachectic  conditions  of  the  system,  and  is  well  deserv- 
ing of  esp-rcial  notice ;  I  mean  that  known  as  periosteal  rheu- 
matism. In  those  parts  of  the  body  where  the  bony  frame- 
work is  thinly  covered  with  integument,  the  periosteum,  the 
fibrous  investment  of  the  bones,  becomes  painful,  tender  on 
pressure,  and  thickened  so  as  to  cause  distinct  projections. 
Thus  nodes,  as  they  are  called,  are  often  formed  on  the  tibia, 
the  ulna,  the  clavicle,  the  sternum,  and  the  cranium.  At  the 
first  onset  of  the  disease,  the  part  affected  may  become  some- 
what swollen  and  puffy  ;  but  as  the  puffiness  subsides,  the  thick- 
ening to  which  I  have  alluded  ensues,  and  forms  firm,  irregular, 
painful  elevations,  exquisitely  tender  to  the  touch.  So  promi- 
nent are  they  in  some  instances,  that  the  eye  alone  suffices  to 
detect  their  existence,  and  even  when  this  is  not  the  case,  they 
are  easily  felt  on  running  the  fingers  along  the  bone.  They 
vary  in  size,  as  in  prominence,  roughness  of  surface,  and 
tenderness,  but  they  are  usually  of  an  inch  or  an  inch  and  a 
half  in  length,  suflficiently  tender  to  be  a  constant  source  of 
pain  and  annoyance,  and  prominent  enough,  and  rough  enough, 
to  be  detected  on  the  most  cursory  examination. 

When  they  occur  on  the  shin-bone,  on  the  breast-bone,  or  the 
collar-bone,  thoy  are  easily  recognized,  and  their  nature  is  not 
very  liable  to  be  mistaken,  but  their  occurrence  on  the  fore- 
head, or  other  parts  of  the  cranium,  gives  rise  to  a  severe  and 
wearing  pain,  which  is  often  mistaken  for  ordinary  headache, 
and  being  improperly  treated  as  such,  proves  exceedingly  obsti- 
nate and  intractable.  Patients  suffering  under  this  form  of 
disease  have  repeatedly  come  under  my  care  at  the  Hospital, 
who,  for  months,  have  been  undergoing  treatment  for  headache 


AGGRAVATED    BY    HEAT.  359 

or  neuralgia  without  deriving  the  slightest  benefit,  and  in 
almost  all  such  cases  immediate  relief  has  been  experienced 
when  the  true  nature  of  their  complaint  has  been  discovered, 
and  appropriate  treatment  pursued. 

This  form  of  the  disease  is  frequently  described  as  occurrring 
only  among  those  who  are  tainted  with  venereal  poison,  or 
whose  systems  are  saturj^ted  by  mercury.  Nothing,  however, 
can  be  more  erroneous  than  such  a  statement.  True  it  is,  as 
already  stated,  that  this  form  of  the  complaint  is  most  common 
in  cachectic  states  of  the  system,  and  is,  therefore,  met  with 
most  frequently — nay,  almost  exclusively — among  those  who 
have  been  depressed  by  the  operation  of  the  syphilitic  poison, 
or  by  long-continued  mercurial  action.  But  it  is  not  necessarily 
confined  to  cases  of  this  sort.  I  have  known  inflammation  of 
the  periosteum  occur  during  the  course  of  a  well-developed 
attack  of  acute  rheumatism,  and  on  several  occasions  have  met 
with  nodes  in  persons  among  whom  I  am  convinced  no  suoh 
agencies  had  been  at  work,  and  in  some  of  whom  it  is  morally 
certain  they  never  could  have  been.  Even  the  existence  of  a 
cachectic  state  of  system  does  not  seem  to  be  a  condition 
essential  to  its  development,  though  the  disease  is  certainly 
most  common  among,  nay  is  usually  confined  to,  those  in  whom 
a  state  of  cachexia  exists. 

The  pains  in  chronic  as  in  acute  rheumatism  are  usually  most 
severe  at  night ;  so  much  so,  indeed,  that  in  many  instances, 
after  the  first  stiffness  has  worn  off  in  the  morning,  they  occa- 
sion little  inconvenience  until  the  patient  is  again  in  bed.  These 
nocturnal  exacerbations  have  been  attributed  by  some  to  the 
agency  of  heat,  and  the  warmth  of  the  bed  has  been  thus  made 
answerable  for  the  manifest  increase  in  the  patient's  sufferings. 
But  although  increased  warmth  is  sometimes  accompanied  by 
an  increase  of  pain,  yet  at  others  it  tends  decidedly  to  its  alle- 
viation ;  and  the  fact  that  an  exacerbation  of  symptoms  toward 
night  is  equally  well  marked  in  many  other  disorders,  occurs 
under  every  condition  of  external  temperature,  and  is  observed 
as  decidedly  when  the  sufferers  do  not  go  to  bed  as  when  they  are 
lying  under  a  load  of  blankets,  is  decisive  as  to  the  incorrect- 


360  CHRONIC    RHEUBIATISM. 

ness  of  tlie  ojjinion  which  wouhl  attribute  this  pecuh'arity  to 
warmth. 

That,  in  many  cases,  tlie  pain  is  aggravated  by  heat,  while 
in  others  it  is  relieved  by  the  same  means  and  to  an  equal  ex- 
tent, is  a  matter  of  common  every-day  experience,  and  theo- 
retically is  a  fact  possessing  little  value.  It  accords  precisely 
with  the  observation  which  has  been  made  in  many  complaints 
in  which  pain  is  a  prominent  feature,  namely,  that  warmth  or 
tepid  applications  are  more  grateful  in  one  instance  or  at  one 
period  of  the  disorder,  while  cold  ones  are  more  grateful  and 
more  serviceable  at  another.  But  in  practice  its  importance  is 
strikingly  manifest,  and  has  been  recognized  ever  since  the  days 
of  Aretreus.  The  cases  which  benefit  most  from  warmth  are  those 
which  occur  chiefly  among  persons  of  a  languid  constitution  ; 
and  in  such  persons  friction  and  stimulating  embrocations, 
together  with  hot  baths,  and  the  internal  administration  of  stim- 
ulant and  sudorific  medicines,  prove  eminently  serviceable,  and 
therefore  should  be  resorted  to  witl40ut  delay.  But  in  those  in 
which  increase  of  temperature  is  productive  of  suffering  rather 
than  of  relief,  the  system  has  usually  appeared  more  prone  to 
become  heated,  and  to  take  on  inflammatory  action.  In  such, 
therefore,  stimulants  should  be  avoided,  and  the  same  principles 
of  treatment  adopted  as  in  the  acute  disease,  though,  of  course, 
proportioned  to  the  energy  and  general  character  of  the  symp- 
toms. 

It  should  be  remembered,  however,  that  even  when  a  dry 
heat  is  prejudicial  to  the  patient,  and  greatly  increases  the 
severity  of  his  pain,  any  remedy  which  gives  rise  to  free  perspi- 
ration is  often  exceedingly  serviceable.  In  this,  as  in  the  more 
acute  form  of  the  disease,  I  have  repeatedly  observed  and  pointed 
out  to  the  pupils  at  the  Hospital,  how  a  patient  who  has  bitterly 
complained  of  the  heat  which  irritated  and  excited  him,  so  long 
as  the  action  of  the  skin  was  suppressed,  has  willingly  admitted 
the  relief  aff'orded  by  a  copious  perspiration,  resulting  from  a 
further  increase  of  temperature  induced  by  a  vapor  or  a  hot- 
air  bath.  If  his  pains  have  not  been  permanently  removed, 
they  have  at  least\been  subdued  or  mitigated  for  a  time. 


1 


TREATMENT    BY    PARTICULAR    MEDICINES.  361  ] 

I 

In  the  treatment  of  chronic  as  of  acute  rheumatism,  it  sliould  i 
be  remembered  that  the  disease  is  engendered  by  a  poison  result-  , 
ing  from  imperfect  or  faulty  assimilation,  and  that  no  cure  can  ' 
be  permanent  until  the  materies  morbi  already  generated  has 
been  eliminated  from  the  system,  and  the  further  formation  of 
such  matter  arrested.  The  judicious  practitioner  should  con-  V 
stantly  bear  in  mind  hoy^  complicated  is  the  machinery  which 
is  out  of  order,  how  closely  one  part  of  it  hinges  upon  another, 
and  how  necessary  it  is  for  the  cure  of  his  patient  that  every  part 
should  Avork  eflSciently.  He  should  endeavor  to  invigorate  the 
system  and  restore  a  normal  state  of  assimilation ;  he  should 
mark  each  deviation  from  the  condition  of  health,  whether  indi- 
cated by  the  tongue,  the  pulse,  or  the  skin,  by  the  urine,  or  the 
alvine  evacuations,  and  according  as  the  derangement  seems 
general  or  local,  so  should  he  vary  and  apportion  his  remedies. 
Above  all  he  sliould  promote  a  free  evacuation  through  the  vari- 
ous channels  by  which  the  effete  materials  of  the  body  are  thrown 
out  of  the  system  ;  he  should  stimulate  the  skin  to  the  function 
of  perspiration  ;  he  should  regulate  the  action  of  the  kidneys 
and  bowels ;  and  should  endeavor  so  to  modify  their  several 
secretions  as  that  every  noxious  matter  shall  be  got  rid  of  with- 
out exhausting  or  depressing  his  patient. 

One  of  the  remedies  which  has  been  found  most  effective  for 
this  purpose,  is  the  ammoniated  tincture  of  guaiacum,  either 
alone  or  in  combination  with  bark.  Ever  since  the  year  1781, 
when  Dr.  Dawson  published  the  successful  termination  of  his 
cases  treated  by  half-ounce  doses  of  this  medicine,  it  has  been 
an  established  favorite  with  the  profession ;  and  in  the  cure  of 
chronic  rheumatism,  occurring  in  persons  of  a  languid  state  of 
system,  its  efficacy  is  quite  equal  to  its  reputation.  But  it  is 
seldom  necessary,  or  indeed  expedient,  to  administer  it  in  such 
full  doses  as  have  been  given  and  recommended  by  some  prac- 
titioners. Dr.  Elliotson,  for  instance,  "  has  known  patients 
who  took  six  drachms  three  or  four  times  a  day  ;"^  and  many 
persons,  following  Dr.  Dawson's  example,  have  given  itinhalf- 

^  Mason  Good's  "Study  of  Medicine,-'  vol.  ii,  p.  281.  Note  by  Samuel 
Cooper. 

24 


362  CHRONIC    RHEUMATISM. 

ounce  doses.  My  own  experience  has  led  me  to  consider  a 
drachm  or  a  drachm  and  a  half  of  the  tincture,  taken  three 
times  a  day,  an  ample  dose  in  ordinary  cases;  and  even  where 
this  has  failed  in  affording  relief,  it  has  never  been  necessary, 
nor  has  it  seemed  expedient,  to  exceed  two  drachms  three  or 
four  times  a  day.  In  doses  such  as  these  it  usually  acts  as  a 
stimulating  evacuant,  increasing  thf  action  of  the  skin,  the 
kidneys,  and  the  bowels ;  and  in  such  doses,  should  it  produce 
a  tendency  to  diarrhoea,  its  action  may  be  controlled,  and  the 
bowels  regulated,  by  the  exhibition  of  opium.  But  in  larger 
doses  its  action  is  more  uncertain.  Dr.  Elliotson,  while  as- 
serting that  "  when  internal  stimulants  are  necessary  in  rheu- 
matism,  he  thinks  this  one  of  the  best,"  acknowledges  that, 
■when  given  in  large  doses,  "it  often  purges  violently,  and  some- 
times produces  the  nettlerash  ;"^  and  although  no  serious  con- 
sequences may  ensue,  yet  the  possibility  of  the  occurrence  of 
such  troublesome  symptoms  is  enough  to  make  us  pause  before 
adopting  such  a  plan  of  treatment. 

The  volatile  tincture  is  particularly  useful  in  chronic  rheu- 
matism from  the  ease  with  wliich,  if  tonics  be  required,  it  may 
be  combined  with  bark  and  other  similar  medicines.  But  the 
Mistura  Guaiaci,  to  which  1  alluded  when  considering  the  treat- 
ment of  acute  rheumatism,  is  also  a  form  in  which  guaiacum 
may  be  employed"  advantageously ;  the  more  so,  when  it  is 
thought  desirable  to  administer  it  freely  without  the  quantity 
of  the  diffusible  stimulant  which  is  contained  in  the  larger  doses 
of  the  tincture. 

There  is  yet  another  form,  however,  in  which  guaiacum  has 
'earned  a  well-merited  reputation  ;  I  mean  in  powder,  as  exist- 
ing in  the  compound  formerly  well  known  by  the  title  of  the 
■"  Chelsea  Pensioner."     The  original  recipe  is  given  below  ;^ 

1  Loc.  cit. 

2  Take  of  Flowers  of  Sul[)liur,  jij  ; 

Cream  of  Tartar,  §j ; 
Powdered  Rhubarb,  5ij  ! 
Guaiacum.  3J  i 
Clarified  Honey,  lb  j  ; 

One  Nutmeg  finely  powdered.      Mix  the  ingredients. 
Two  large  tea^pooDfuIs  to  be  taken  night  and  morning,  and  to  be  persevered 


TREATMENT    BY    PARTICULAR    MEDICINES.  363 

and  in  tliese,  or  in  somewhat  varying  proportions,  this  medi- 
cine has  repeatedly  effected  a  cure  after  all  other  preparations 
have  been  tried  in  vain.  In  most  instances,  however,  the  pro- 
portion of  guaiacum  may  be  advantageously  increased,  and 
when  the  bowels  are  costive,  fifteen,  twenty,  or  even  thirty 
grains  may  be  given  at  a  dose.  It  is  especially  useful  in  old 
lingering  cases,  accompanied  by  torpor  of  the  intestinal  secre- 
tions, and  a  sluggish,  inactive  condition  of  the  skin. 

On  the  same  principle  as  that  on  which  guaiacum  has  been 
recommended,  many  other  remedies  of  a  warm  and  stimulating 
nature  have  been  administered  in  obstinate  lingering  cases. 
Among  these  may  be  mentioned  Camphor,  the  oils  of  Turpen- 
tine, Cajeput,  Juniper,  Sassafras,  and  Amber,  the  balsams  of 
Copaiba  and  Peru;  and  aromatic  and  pungent  plants,  such  as 
mustard,  horseradish,  and  the  Arnica  Montana.^  Mezereon  is 
sometimes  used,  and  Senega  and  Dulcamara  have  also  been 
recommended.  All  these  agents,  either  alone  or  in  combina- 
tion with  opium,  which  often  proves  a  valuable  adjunct,  have 
been  found  extremely  serviceable,  and  none  more  so  than  oil 
of  turpentine.  Indeed,  many  of  the  medicines  just  enumerated 
are  of  a  terebinthinate  nature,  and  were  it  not  for  its  nauseous 
flavor,  and  for  the  strangury  which  often  follows  its  use,  the 
common  oil  of  turpentine,  administered  in  drachm  or  half 
drachm  doses,  would  be  very  generally  adopted  as  a  cure  in 
obstinate  and  protracted  cases.  In  combination  with  bark,  I 
have  sometimes  known  it  particularly  useful. 

Sassafras  is  a  remedy  which  is  seldom  given  in  this  country, 
except  in  the  combination  which  finds  a  place  in  our  Phaima- 
copocia  under  the  title  of  Decoctum  Sarzte  Compositum.  I  am 
satisfied,  however,  that  it  may  be  administ  red  advantageously 
in  many  instances  in  which  sarsaparilla  ie  not  needed,  and  in 
doses  exceedinor  those  in  which  it  is  taken  in  the  Pliarmaco- 
poeia  preparation  just  alluded  to.     When  the  circulation  has 

in  until  the  wliole  is  consumed.  For  the  first  three  iiights,  a  large  tumbler  of 
warm  rum  and  water  to  be  taken  at  bedtime,  or,  il  fever  be  present,  white 
wine  instead  of  rum. 

'  For  formula,  see  p.  322. 


364  CHRONIC    RHEUMATISM. 

been  languid,  the  skin  dry,  and  the  kidneys,  liver,  and  bowels 
inactive,  as  they  are  in  many  forms  of  chronic  rheumatism,  the 
greatest  benefit  frequently  results  from  its  use  either  alone 
or  in  conjunction  with  any  other  remedies  which  the  circum- 
stances of  the  case  may  seem  to  require.  It  is  stimulant  and 
sudorific  in  its  action,  and  in  certain  instances  appears  to  exer- 
cise a  curative  influence,  Avhich  is  not  possessed  by  guaiacum 
nor  by  any  other  remedy  of  the  same  class.  Moreover,  it  is 
not  purgative  like  guaiacum,  and,  consequently,  is  available  in 
many  instances  in  which  the  administration  of  that  medicine  is 
inadmissible.^ 

Whenever  it  is  given,  diluents,  such  as  hot  weak  tea,  barley 
water,  or  even  plain  water,  should  be  taken  plentifully,  with 
the  view  of  promoting  diuresis  and  perspiration ;  and  this  ap- 
plies not  only  to  the  whole  class  of  stimulating  and  sudorific 
medicines  of  which  this  is  one,  but  also  to  the  saline  medicines, 
which  in  rheumatism  and  rheumatic  gout  are  given  as  alteratives 
and  eliminatives.  There  cannot  be  a  doubt  that  free  dilution  ex- 
ercises a  most  important  influence  on  the  action  of  almost  all  the 
remedies  which  prove  useful  in  this  class  of  disorders,  and  that  a 
dose  which  would  excite  nausea  and  irritation  of  the  stomach 
when  taken  in  a  concentrated  form,  is  often  productive  of  ex- 
cellent results  Avhen  aided  in  its  action  by  water.  Hence, 
probably,  the  wonderful  efficacy  of  the  natural  mineralized 
waters,  and  hence,  also,  the  superior  effects  which  often  ensue 
after  taking  the  weak  infusions  or  teas  which  are  the  favorite 
remedies  of  the  poor  and  the  nostrums  of  so-called  herbalists. 
I  am  firmly  convinced  that .  our  medicines  frequently  fail  in 
their  operation  for  lack  of  sufficient  dilution ;  and,  although  I 
do  not  counsel  their  administration  in  an  inconveniently  bulky 
form^  I  do  most  strongly  urge  the  taking  of  a  copious  draught 
of  water  or  some  harmless  diluent  after  each  dose  of  the 
remedy. 

'  The  subjoined  formula  is  one  which  may  be  employed : 
J^.  Sassafras  Radicis  concisi,  §iss  ; 
Mezerii,  5'v ; 

Taraxici  Radicis  concisi,  §iij ; 
Aquaj  ferventis,  Oj. 
Macera  per  horas  tres  et  cola.     Dosis  Liquoris  colati,  ^j  to  ^iss. 


TREATMENT    BY   PARTICFLAR    MEDICINES.  365 

Sulphur  is  an  agent  which  sometimes  proves  peculiarly  val- 
uable in  the  treatment  of  chronic  rheumatism,  especially  when 
the  skin  is  inactive.  Among  the  poor  it  has  long  been  a 
favorite  remedy,  and  by  its  action  has  doubtless  contributed  not 
a  little  to  the  reputation  of  the  powder  termed  the  "  Chelsea 
Pensioner,"^  of  which  it  forms  a  large  proportion.  Adminis- 
tered in  half-drachm  doses  three  or  four  times  in  the  course  of 
the  day,  and  aided  in  its  action  by  the  stimulating  effect  of  the 
simple  vapor  or  the  sulphur  vapor  bath,  it  is  often  extremely 
efficacious  in  removing  chronic' muscular  pains,  and  there  are  few 
remedies  within  the  range  of  the  Pharmacopoeia  on  which  so  much 
reliance  can  be  placed.  Its  use,  however,  should  be  restricted 
to  muscular  and  neuralgic  rheumatism  ;  for  in  the  articular 
form  of  the  disease,  accompanied  by  synovial  effusion,  and  in 
periosteal  rheumatism,  it  is  far  inferior  to  other  remedies,  if, 
indeed,  it  be  not  altogether  valueless. 

Colchicum  is  of  far  less  service  in  chronic  rheumatism  than 
in  the  more  active  form  of  the  disease,  and  its  administration 
should  be  restricted  to  those  cases  in  which  the  liver  is  inactive 
and  in  which  the  joints  are  swollen,  with  effusion  within  the 
capsule,  and  the  pain  is  aggravated  by  heat.  Under  such  cir- 
cumstances, in  combination  with  alkalies,  diuretics,  and  opiates, 
it  sometimes  proves  exceedingly  beneficial. 

The  valuable  properties  of  iodide  of  potassium  are  seldom 
displayed  when  the  muscular  structures  are  the  parts  affected  ; 
but  they  are  strikingly  manifest  when  the  patient  is  out  of 
health  and  the  periosteum  is  implicated.  In  such  cases,  admin- 
istered in  five  or  eight  grain  doses,  it  speedily  gives  relief,  not 
unfrequently  removing  the  pain  and  swelling  in  the  course  of 
a  few  days  ;  and  even  when  the  disease  proves  more  intractable, 
and  lingers  on  for  several  weeks,  the  intensity  of  the  pain  is 
soon  subdued,  and  the  patient's  health  gives  tokens  of  improve- 
ment. Indeed,  so  potent  is  the  influence' of  this  medicine  over 
this  particular  form  of  the  disease,  that  in  many  instances  the 
cure  may  be  safely  intrusted  to  its  unassisted  powers ;  but  in 
old-standing  cases,  where  the  health  is  much  impaired,  it  is 

»  See  p.  362. 


366     *  CHRONIC    RHEUMATISxM. 

advisable  to  combine  it  Avith  bark  and  sarsaparilla,  and  to  ex- 
hibit a  full  dose  of  opium  at  night.  The  bowels,  in  such  a  case, 
should  be  regulated  by  gentle  laxatives,  and  the  general  health 
sustained  by  a  full  and  nutritious  diet. 

A  valuable  adjunct  to  the  iodide  of  potassium  in  many  of 
these  cases  is  the  bark  of  the  Daphne  Mezereon.  This  remedy 
was  introduced  to  the  notice  of  the  profession  by  Dr.  Alexan- 
der Russell,^  as  an  efficacious  cure  for  venereal  nodes,  and  in 
small  doses  is  frequently  administered  in  the  compound  decoc- 
tion of  sarsaparilla,  of  which  it  forms  one  of  the  ingredients. 
But  however  valuable  its  properties  may  be,  and  their  value  in 
many  instances  is  undoubted,  they  cannot  be  exerted  to  any 
advantage  in  the  small  doses  in  which  it  is  usually  exhibited, 
and,-  therefore,  whenever  it  seems  desirable  to  give  it,  either 
alone  or  in  conjunction  with  sarsaparilla,  an  infusion  should  be 
made  of  half  an  ounce  of  the  root  to  a  pint  of  water.  This 
when  strained  may  be  given  in  doses  of  an  ounce  or  an  ounce 
and  a  half,  in  conjunction  with  the  iodide  and  extract  of  sar- 
saparilla ;  and  though  it  does  not  possess  the  power  attributed 
to  it  by  Dr.  Russell,  of  curing  secondary  syphilis,  it  certainly 
proves  stimulant,  diaphoretic,  and  alterative,  and,  in  many 
instances,  is  said  to  produce  effects  such  as  cannot  be  obtained 
from  the  iodide  alone.  In  purely  muscular  rheumatism,  it 
sometimes  exerts  a  beneficial  influence,  but  its  good  effects  are 
most  strikingly  displayed  in  the  class  of  cases  which  are  ben- 
efited by  Iodide  of  Potassium. 

The  late  Dr.  Percival  was  in  the  habit  of  prescribing  the 
cod-liver  oil  in  chronic  rheumatism;  and  Dr.  Bardsley,  in  his 
valuable  medical  reports,  speaks  favorably  of  its  curative  influ- 
ence. I  have  sometimes  administered  it  alone  in  half-ounce  doses 
when  the  patient  has  been  thoroughly  out  of  health  ;  and  in  some 
such  cases  with  undoubted  benefit.  But,  under  ordinary  circum- 
stances, its  efficacy  appears  to  be  greatly  increased  by  its  exhibi- 
tion in  conjunction  Avith  other  remedies,  and  therefore  whenever 
a  case  occurs  in  which,  from  the  cachectic  condition  of  the  pa- 
tient, its  administration  seems  likely  to  be  attended  with  benefit, 

'  See  "  Medical  Observ.  and  Inquiries,"  vol.  iii,  p.  194. 


TREATMENT    BY    PARTICULAR    MEDICINES.  367 

I  usually  give  it  in  the  form  of  an  emulsion  with  the  Liquor 
Potassne  and  Iodide  of  Potassium;  or  else  combine  it,  if  circum- 
stances permit,  with  the  syrup  of  the  Iodide  of  Iron.  When 
the  appetite  is  indifferent,  the  circulation  languid,  and  the  pulse 
weak,  the  Sulphate  of  Quinia,  in  combination  with  the  mineral 
acids,  aided,  if  necessary,  by  some  preparation  of  Iron,  has  ap- 
peared to  me  a  more  useful  addition  than  the  Liquor  Potassse 
and  Iodide  of  Potassium. 

Hydrochlorate  of  Ammonia  is  a  remedy  of  singular  efficacy 
in  chronic  rheumatism,  yet,  strange  to  say,  is  almost  unknown 
as  such  to  the  profession.  In  no  treatise  on  rheumatism  which 
I  have  had  an  opportunity  of  consulting,  do  I  find  the  slightest 
notice  of  its  virtues.  Yet  its  action  on  the  skin  is  admitted  by 
those  who  have  watched  the  effects  of  its  internal  administra- 
tion. Sunderlin  reports,  that  it  acts  as  an  "excitant"  to  the 
bowels,  the  skin,  and  the  kidneys  ;  that  "  it  not  only  increases 
secretion,  but  improves  nutrition  and  assimilation,"  and  "pro- 
motes not  only  the  mucous  secretions,  but  also  cutaneous  exha- 
lation."^ Certain  it  is,  that  in  fifteen  or  twenty  grain  doses, 
in  combination  with  bark,  it  sometimes  produces  marvelously 
good  results,  and  is  frequently  serviceable  when  other  remedies 
have  proved  inefficient.  The  character  of  the  secretions  im- 
proves under  its  influence,  the  skin  acts  more  freely  and  regu- 
larly, and  the  disease  gradually  subsides.  Its  beneficial  effects, 
however,  are  most  remarkably  exerted  in  muscular  rheumatism  : 
and  when  the  periosteum  or  the  joints  are  affected,  it  seldom 
afi"ords  us  much  assistance. 

Arsenic  is  another  remedy  which  in  obstinate  cases  charac- 
terized by  dryness  and  harshness  of  the  skin  is  often  produc- 
tive of  excellent  effects,  improving  the  health,  augmenting  the 
appetite,  stimulating  the  capillary  circulation,  and  restoring 
tiie  natural  perspiratory  action.  Its  antirheumatic  virtues, 
however,  are  as  yet  but  little  known  to  the  profession,  and  it 
was  mere  accident  which  first  directed  my  attention  to  it.  In 
November,  1853,  a  gentleman  consulted  me  respecting  rheu- 

1  "  Handbuch  der  Speciellen  Hulmeltellelire."  Quoted  iu  Pereira's  "  Alateria 
Medica." 


368  CHRONIC  rheumatism. 

matic  pains  in  tlie  joints,  whicli  had  tormented  him  more  or  less 
for  seven  years.  These  pains  had  supervened  on  an  attack  of 
articular  rheumatism,  which  lasted  three  weeks,  and  was  accom- 
panied by  pain,  heat,  and  swelling  of  ihe  affected  parts.  The 
inflammatory  symptoms  had  never  since  returned,  nor  had  there 
been  more  than  an  occasional  tumefaction  for  a  few  days  ;  but 
lately  the  pains  had  been  unceasing,  and  had  given  rise  to 
excessive  stiffness  and  soreness  of  the  whole  body,  especially 
of  the  joints.  He  had  taken  guaiacum,  mercury,  iodide  of 
potassium,  sarsaparilla,  and  all  the  ordinary  remedies  for  rheu- 
matism, and  had  tried  the  effect  of  baths  and  mineral  waters  in 
this  country  and  on  the  Continent.  Under  these  circumstances 
I  was  at  a  loss  what  medicine  to  prescribe,  but  finding  that 
the  pains  were  of  a  somewhat  intermittent  character,  I  tried 
full  doses  of  quinine  in  the  first  instance,  and  subsequently,  as 
they  failed,  administered  arsenic.  The  pains  soon  yielded,  the 
appetite  improved,  and  I  had  the  satisfaction  of  seeing  my 
patient  regain  his  health.  Since  that  time  I  have  prescribed 
it  in  several  instances  with  good  effect;  and  although,  as  stated 
at  p.  320,  when  speaking  of  its  action  on  rheumatic  gout,  I  do 
not  feel  quite  satisfied  as  to  its  modus  operandi,  and  am  unable 
as  yet  to  point  out  the  precise  conditions  under  which  its  bene- 
ficial influence  is  most  likely  to  be  exerted,  the  impression  is 
strong  in  my  mind  that  the  cases  which  derive  most  benefit 
from  its  administration  are  those  in  which  the  skin  is  inactive, 
the  bowels  regular,  the  kidneys  healthy,  and  the  urine  clear, 
but  of  low  specific  gravity — in  cases,  in  fact,  characterized  by 
want  of  tone  and  nervous  energy  in  the  system.  My  experi- 
ence, however,  is  at  present  very  limited,  and  the  grounds  for 
an  opinion  therefore  very  imperfect,  and  I  shall  be  glad  to 
receive  information  on  the  subject  from  any  one  who  will  kindly 
favor  me  with  it. 

In  some  obstinate  cases  of  chronic  rheumatism,  more  espe- 
cially when  supervening  in  a  system  which  has  been  poisoned 
by  the  syphilitic  virus,  it  is  expedient  to  have  recourse  to  the 
exhibition  of  mercury.  Indeed,  many  such  cases  are  absolutely 
incurable  until  its  agency  is  employed ;  and  in  such  instances 


TREATMENT    BY    PARTICULAR    MEDICINES.  369 

its  administration  is  speedily  productive  of  good  effect.  Within 
the  last  four  years  I  have  known  several  patients  recover  rapidly 
under  the  use  of  various  antirheumatic  remedies,  in  which  they 
had  fruitlessly  persevered  for  months  prior  to  the  exhibition  of 
a  mercurial.  But,  in  ordinary  cases,  mercurialization  is  need- 
less, if  not  hurtful.  It  sometimes  proves  useful  when  there  is 
excessive  tenderness  with  pufBness  about  a  periosteal  swelling, 
as  also  when  a  joint  is  enlarged,  and  continues  in  a  state  of 
irritation  uninfluenced  by  other  remedial  agents,  but  it  is  always 
depressing,  and  should  not  be  employed  unless  its  influence  is 
demanded  either  by  the  urgency  of  the  local  symptoms  or  by 
the  failure  which  has  attended  the  administration  of  other  rem- 
edies. If  the  local  symptoms  are  severe,  it  may  be  necessary 
to  push  it  gradually  to  salivation,  but  in  other  instances  it  is 
desirable  to  obtain  its  specific  influence  without  the  depression 
occasioned  by  ptyalism.  For  this  purpose  the  bichloride  of 
mercury,  or  the  biniodide,^  formed  by  adding  the  iodide  of 
potassium  to  the  Liq.  Hydrarg.  Bichloridi,  prove  very  efficient 
agents,  and  pains  which  have  long  resisted  every  other  remedy 
will  often  yield  rapidly  to  their  influence.  Indeed,  the  binio- 
dide  kept  in  solution  by  an  excess  of  iodide  of  potassium,  and 
given  in  combination  with  bark,  has  proved  in  my  hands  the 
most  valuable  of  all  medicines  in  rheumatism  which  has  super- 
vened in  a  system  tainted  by  the  syphilitic  poison,  and  in 
several  instances  has  eff"ected  a  speedy  cure  after  the  bichlo- 
ride had  been  given  in  vain.  Occasionally  it  produces  slight 
griping  and  diarrhoea,  but  these  symptoms  are  easily  con- 
trolled, and  cease  directly  the  medicine  is  discontinued,  or 
is  exhibited  in  smaller  doses.  The  possibility  of  their  occur- 
rence, therefore,  forms  no  bar  to  its  administration  in  appro- 
priate cases,  and  its  curative  action  is  so  strongly  marked,  and 

1  The  following  are  forrmilaj  I  often  employ : 
^.  Liq.  Hydrar  Bichloridi,  3J-3'J  j  ^i"'  Liq.  Hydrar.  Bichloridi,  3i-3'j  ! 

Potassii  lodidi,  gr.  v-x  ;  Potassii  lodidi,  gr.  v-x  ; 

Extract!  Sarzoe,  3ss-3J ;  Syrupi  Sarzoa,  3'j-3''j  i 

Decocti  Cinchona?,  §iss.  Tincturae  Cinchonae  Co.,  3'-3'J ! 

M.  ft.  Haustus.  Decocti  Cinchonae,  ad.  ^iss. 

M.  ft.  Haustus. 


370  CHRONIC    RHEUMATISM. 

SO  speedily  produced,  that  I  never  hesitate  to  recommend  its 
exhibition  whenever  its  agency  is  required. 

Opiates  seem  especially  called  for  in  chronic  rheumatism,  by 
the  obstinacy  and  weariiig  nature  of  the  pain,  and  certainly,  in 
some  instances,  their  influence  for  good  appears  to  extend  not 
only  to  temporary  abatement  of  suffering,  but  to  the  subjuga- 
tion of  that  action  on  which  the  pain  and  suffering  depend.  In 
my  experience,  however,  this  rarely  has  been  the  case.  Gen- 
erally they  have  done  little  more  than  assuage  present  pain,  and, 
by  obtaining  for  the  patient  a  respite  from  suffering,  afford  him 
that  rest  which  is  as  essential  to  the  recovery  of  his  health  as 
to  his  hourly  personal  comfort.  This,  then,  is  the  vieAV  with 
which  they  should  be  administered,  and  their  exhibition  there- 
fore should  be  limited  to  cases  in  which  Morpheus  is  a  stranger, 
and  must  be  wooed  before  he  will  lend  his  assistance.  Battley's 
sedative  solution  and  the  Morphia  Acetas  are  admirable  and 
efficient  preparations,  but  in  no  form  do  opiates  prove  more 
serviceable  in  this  complaint,  than  in  that  of  the  celebrated 
Dover's  powder,  the  Pulvis  Ipecacuanhge  Compositus  of  the 
Pharmacopoeia. 

Sometimes,  however,  opiates  disagree  with  the  stomach,  or 
fail  in  giving  relief.  In  either  case,  recourse  may  be  had  to 
other  sedatives,  which,  under  certain  circumstances,  prove  more 
efficacious  than  the  preparations  of  opium.  This  is  so  especially 
when  the  pain  assumes  a  neuralgic  character.  Cases,  for  instance, 
Avhicli  have  long  resisted  opium  and  the  various  preparations 
of  morphia,  have  yielded  as  if  by  magic  under  the  influence  of  a 
full  dose  of  belladonna.  The  same  may  be  said  of  stramo- 
nium, conium,  and  hyoscyamus.  But  in  no  instance  have  I  seen 
more  speedy  or  more  complete  relief  from  suffering  than  has 
sometimes  followed  the  exhibition  of  the  ethereal  tincture  of 
the  Cannabis  Indica.  In  one  patient,  a  medical  friend,  whom 
I  was  not  asked  to  see  until  after  all  ordinary  sedatives  had 
been  tried,  a  single  dose  of  the  tincture  gave  immediate  relief, 
and  was  followed  by  a  long  refreshing  sleep,  to  which  he  had 
been  a  stranger  above  two  months.  A  similar  effect,  though 
less  strongly  marked,  has  resulted  from  its  use  in  many  other 


TllEATMENT    BY    PARTICULAR    MEDICINES.  371 

instances.  But  great  caution  must  be 'observed  in  the  employ- 
ment of  this  remedy.  If  it  fails  in  producing  a  narcotic  effect, 
it  is  apt,  even  in  doses  of  twelve  or  fifteen  minims,  to  produce 
considerable  excitement,  and  its  use,  therefore,  should  be 
restricted  to  cases  accompanied  by  nervous  exhaustion.  Indeed, 
its  assistance  appears  to  be  called  for  in  the  very  cases  in  which 
opium,  belladonna,  and  other  pure  narcotics,  not  unfrequently 
prove  useless ;  while  in  cases  characterized  by  nervous  excite- 
ment, and  accompanied  by  a  hot  skin  or  a  hurried  pulse,  its 
action  proves  hurtful  rather"  than  beneficial. 

There  is  yet  another  sedative  which  deserves  especial  notice 
as  being  remarkably  serviceable  in  many  forms  of  chronic 
rheumatism.  I  allude  to  aconite,  a  remedy  which  was  intro- 
duced by  Stoerk,  of  Vienna,  in  1762,  and  was  largely  used  in 
this  country  by  the  late  eminent  Dr.  Pitcairn,  of  St.  Bartholo- 
mew's Hospital.  Within  the  last  seven  years  I  have  prescribed 
the  tincture  in  a  large  number  of  cases;  and  in  many  which 
were  unattended  by  redness  and  swelling,  its  remedial  efi"ects 
have  been  strongly  marked.  If,  in  some  instances,  it  has  not 
exercised  any  control  over  the  violence  or  duration  of  tlie  pain, 
it  has  acted  almost  magically  in  others,  and  relief  has  followed 
as  speedily  after  its  exhibition,  as  it  does  not  unfrequently 
after  its  external  application.  Sometimes  it  produces  a  sen-, 
sation  of  heat  and  tingling  in  the  extremities,  constriction 
across  the  throat,  and  a  constant  desire  to  swallow;  but  unless 
such  symptoms  are  persistent,  and  accompanied  by  vertigo, 
faintness,  palpitation,  or  some  other  disagreeable  sensation,  it 
is  not  necessary  on  that  account  to  discontinue  its  exhibition. 
When  the  secretions  are  out  of  order,  and  the  general  health 
is  impaired,  it  rarely  proves  eflficacious  until  other  medicines 
have  been  administered;  but  in  many  cases  of  chronic  rheu- 
matism, unconnected  with  a  venereal  taint,  when  the  symptoms 
are  those  of  aching  pain  and  stiffness,  without  any  redness  or 
swelling  of  the  parts,  or  any  notable  derangement  of  the  secre- 
tions, it'  is  valuable  beyond  all  other  remedies  we  possess. 
Observation,  however,  has  led  me  to  believe  that  it  is  useless 
to  persevere  in  its  administration,  if  some  relief  be  not  speedily 


372  CHRONIC    RHEUMATISM. 

obtained;  whereas,  if  it  prove  sedative  in  its  action,  its  use 
should  be  persisted  in,  and  the  dose  cautiously  increased.  Dr. 
Mantell,  of  Bath,  who  has  used  it  extensively  during  the  last 
twenty-five  years,  and  has  kindly  favored  me  with  the  result 
of  his  experience,  reports  most  favorably  of  its  curative  influ- 
ence. 

Aconite  is  said  to  be  diuretic  and  diaphoretic  in  its  action ; 
but  although  undoubtedly  it  often  excites  perspiration,  it  has 
so  rarely  displayed  any  diuretic  qualities  in  the  cases  which 
have  fallen  under  my  observation,  that  I  suspect  the  occurrence 
of  diuretic  symptoms  has  been  a  mere  coincidence.  Five  or 
six  minims  of  the  Pharmacopoeia  tincture  may  be  given  in  the 
first  instance,  twice  or  three  times  a  day,  and  may  be  gradu- 
ally, but  cautiously,  increased  to  ten  or  even  twelve  minims. 
But  considerable  difference  exists  in  this  respect,  according  to 
the  degree  of  care  which  has  been  exercised  in  preparing  the 
tincture,  and  to  the  combination  in  which  it  is  administered. 
For  although  the  dose  of  the  tincture  ordinarily  met  with  in 
the  shops  may  be  increased,  in  some  instances,  to -ten  or  even 
twelve  minims,  such  is  rarely,  I  may  almost  say  never,  the 
case  in  regard  to  a  carefully  prepared  tincture.  So,  again,  if 
the  tincture  be  given  in  combination  with  alkalies,  the  aconi- 
,tine  is  precipitated,  and  unless  great  acidity  exist  in  the 
stomach,  the  remedy  is  rendered  almost  inert;  whereas,  given 
in  conjunction  with  a  few  drops  of  dilute  sulphuric  acid,  its 
solubility  is  insured  and  its  full  power  is  exerted.  Hence  it 
must  not  be  inferred,  because  ten  or  twelve  minims  are  readily 
borne  when  taken  in  an  alkaline  mixture,  that  the  same  dose 
may  be  administered  with  impunity  if  the  alkalies  are  omitted, 
and  the  mixture  is  made  eitiier  acid  or  neutral.  I  have  known 
one  instance  in  which  disagreeable  effects  were  thus  produced, 
and  can  well  conceive  it  possible  for  dangerous  symptoms  to 
supervene.  Therefore,  in  a  matter  of  so  much  importance,  I 
deem  it  advisable  in  every  instance  to  administer  aconite  in  an 
acid  mixture,  in  order  that  the  full  strength  of  the  dose  may 
be  felt  at  once.  Further,  I  always  think  it  right  to  insist  that 
■wherever  the  mixture  is  dispensed  in  the  first  instance  it  shall 


TREATMENT    BY    PARTICULAR    MEDICINES.  373 

be  made  up  for  the  future,  so  as  to  insure  a  uniformity  in  the 
strength  of  the  tincture,  and  consequently  in  the  dose  of  the 
medicine. 

In  that  form  of  disease  which  is  known  as  lumbago,  brisk 
purgatives  are  some  of  our  most  efficient  allies,  and  usually 
should  be  made  use  of  at  the  commencement  of  the  attack  in 
conjunction  with  alkalies  and  diuretics.  Their  efficacy,  how- 
ever, varies  according  to  the  amount  and  character  of  the 
alvine  and  urinary  secretions.  When  the  urine  is  scanty, 
high  colored,  or  loaded,  the  bowels  costive  or  the  dejections 
dark  colored  and  offensive,  they  are  almost  always  of  inesti- 
mable service,  and  a  large  turpentine  and  castor  oil  enema,  or 
a  few  doses  of  colocynth  and  calomel,  administered  at  bedtime, 
followed  each  morning  or  on  alternate  days  by  a  black  draught, 
containing  half  an  ounce  of  the  potassio-tartrate  of  soda,  and 
thirty  minims  of  colchicum  wine,  have  often  gone  far  toward 
effecting  a  cure.  But  when  the  urine  is  abundant  and  light 
colored,  the  bowels  regular,  and  the  dejections  natural,  the 
value  of  purgatives  is  not  so  apparent.  Indeed,  so  little  benefit 
has  usually  resulted  from  their  employment  in  such  cases  that 
I  now  very  rarely  have  recourse  to  their  administration.  In 
the  former  instances,  the  pain  is  probably  connected  more  or 
less  intimately  with  irritation  of  the  lumbar  and  sacral  nerves, 
and  this  is  relieved,  not  only  by  the  full  evacuation  of  the 
bowels  which  follows  the  use  of  purgatives,  but  by  the  change 
induced  in  the  character  of  the  secretions.  In  the  latter,  the 
lumbar  muscles  and  their  fasciae  and  tendons  are  the  parts 
principally  affected,  and  hence  the  remedies  adopted  for  their 
relief  should  have  relation  to  their  superficial  position,  and  to 
the  more  purely  neuralgic  character  of  the  pain.  Though 
internal  remedies  should  not  be  neglected,  our  main  reliance 
must  be  on  local  applications.  If  the  urine  be  turbid,  and  the 
case  be  attended  by  symptoms  of  local  congestion,  cupping  on 
the  loins  is  of  essential  service,  and  dry  cupping  may  be  often 
employed  beneficially  when  it  is  not  thought  desirable  to 
abstract  blood.  Baths  are  also  valuable  agents,  particularly 
the  warm  bath,  rendered  alkaline  by  the  addition  of  carbonate 


374 


CHRONIC    RHEUMATISM. 


of  soda  or  potash,  as  are  also  fomentations,  formed  by  placing 
across  the  loins  flannel  wetted  with  an  alkaline  and  opiate  solu- 
tion, and  covered  with  a  piece  of  flannel.  When,  on  the  other 
hand,  there  are  no  symptoms  of  local  congestion,  and  the  case 
appears  to  be  of  a  neuralgic  character,  electricity  and  galvan- 
ism may  be  tried  with  a  fair  prospect  of  affording  relief.  In 
such  cases  the  continuous  current  should  be  employed,  and  it 
cannot  be  applied  more  satisfactorily  than  by  means  of  one  of 
Pulvermacher's  chain  batteries.  Stimulating  embrocations, 
followed  by  sedative  fomentations  kept  constantly  applied  to 
the  loins, ^  are  also  very  useful  in  obstinate  cases,  as  are  also 
mustard  poultices,  and  plasters  of  a  stimulating  or  of  a  sooth- 
ing character.  In  some  instances,  after  the  more  active  symp- 
toms have  subsided,  friction  with  the  naked  hand,  with  a  French 
flannel  brush,  or  with  a  horse-hair  glove,  followed  by  a  simple 
flannel  bandage  covered  with  oiled  silk  to  prevent  evaporation, 
or  a  band  of  Markwick's  epithem  worn  across  the  loins,  is  suffi- 
cient to  afford  permanent  relief. 

A  useful  external  application  in  Lumbago,  as  well  as  in  Stiff"- 
neck  and  other  forms  of  muscular  rheumatism,  is  that  which 
has  been  termed  Sir  Anthony  Carlisle's  blister,  an  agent  com- 
paratively unknown  to  the  profession.  It  consists  in  the  appli- 
cation to  the  skin,  over  the  afiected  part,  of  a  small  flat  iron, 
gently  heated  in  a  spirit-lamp  or  boiling  water.  The  operation 
is  completed  in  a  few  seconds,  is  productive  of  little  or  no  pain, 

'  Subjoined  are  two  very  useful  forms  of  applications  in  these  cases : 
^.  Olei  Cajeputi,  vel  Olei  Origani,  vel  Olei  Succini,  5^; 
Olei  Terebinthinne,  5^'^ 

Linimenti  Ammoniie,  vel  Tinctura;  Aconiti,  3^j- 
M.  ft.  Linimentum. 

I^.  Liquoris  Opii  Sedativi,  ^i; 
Extract!  Belladonnoe,  5'; 
Glycerini,  §iss; 
Tincturas  lodinii  Co.,  3'^- 
M.  ft.  Lotio  pro  lumborum  fotu  adhibendar. 
To  the  former  may  be  added  3'^'  of  the  Tincture  of  the  Arnica  Montana, 
which  is  oftentimes  of  the  greatest  service ;  but  if  its  assistance  is  had  recourse 
to,  it  will  be  necessary  to  watch  closely  the  effect  produced  on  the  skin,  inas- 
much as  a  very  troublesome  eruption  is  apt  to  result  when  its  use  is  long  per- 
severed in. 


TREATMENT    BY   PARTICULAR    MEDICINES.  375 

and  is  immediate  in  its  effects.  Among  the  poorer  classes  of 
the  community,  the  practice  of  ironing  the  painful  part  with  a 
laundress's  iron,  the  skin  being  covered  with  a  piece  of  thin 
flannel  or  brown  paper,  had  long  been  in  vogue  in  various 
forms  of  muscular  rheumatism,  but  it  was  not  till  the  year 
1826,  when  Sir  Anthony  Carlisle  addressed  a  letter  to  Sir  Gil- 
bert Blane,  describing  the  benefits  derivable  from  the  appli- 
cation of  a  hot  iron  to  the  naked  skin,  and  recommending  a 
peculiar  form  of  instrument  for  the  purpose,  that  the  attention 
of  the  profession  w^as  directed  to  the  subject.  Of  late  years, 
Dr.  Corrigan,  of  Dublin,  and  Dr.  Day,  of  St.  Andrews,  have 
borne  additional  testimony  to  the  value  of  this  remedy,  and 
have  published  a  series  of  cases  successfully  treated  by  its 
means  ;  and  to  these  gentlemen  the  profession  is  indebted  for 
the  revival  of  an  obsolete,  though  useful  practice. 

The  instrument  recommended  by  Dr.  Day^  "is  a  metal  but- 
ton, about  half  an  inch  in  diameter  and  a  quarter  of  an  inch  in 
thickness,  connected  by  an  iron  shank  Avith  a  small  wooden 
handle.  The  whole  instrument,"  he  says,  "resembles  a  very 
small  hammer.  On  heating  the  button,  which  is  effected  in 
about  a  quarter  of  a  minute  by  the  flame  of  a  spirit-lamp,  I 
place  the  end  of  the  forefinger  on  the  curve.  When  the  heat 
becomes  uncomfortable  to  the  finger,  the  instrument  is  ready 
for  use.  Dr.  Corrigan's  mode  of  applying  it  is  to  touch  the  sur- 
face of  the  part  affected,  at  intervals  of  half  an  inch,  as  lightly 
and  rapidly  as  possible.  I  have  usually  found  more  service 
from  very  lightly  drawing  the  flat  surface  of  the  heated  but- 
ton over  the  affected  part,  so  as  to  act  on  a  greater  extent  of 
surface.  The  cuticle  is  never  raised,  and  the  only  visible  effect 
is  a  slight  degree  of  local  redness,  either  in  lines,  according  to 
my  plan,  or  in  circular  patches,  if  Dr.  Corrigan's  directions  are 
folloAved."  Dr.  Day  concludes  by  expressing  his  opinion  "  that 
the  practitioner  who  will  give  the  thermic  treatment  a  fair  trial 
will  not  readily  abandon  a  remedial  agent  by  which  human 
suffering  can  be  so  easily  and  rapidly  alleviated."  In  advo- 
cating the  use  of  his  favorite  remedy,  Dr.  Day  asserts^  that 
^  Day,  "  Oa  Diseases  of  Advanced  Life."     Appeiidix.  *  Loc.  cit. 


376  cnRONic  rheumatism. 

he  "  never  met  with  a  case  of  lumbago  which  did  not  completely 
yield  to  three  or  four  of  these  trivial  operations."  But  judging 
from  my  own  very  limited  experience  in  the  use  of  this  appli- 
cation, I  should  say  that  it  often  fails  in  affording  relief,  and 
proves  useful  in  exact  proportion  as  the  pain  is  truly  neuralgic. 
In  lumbago,  accompanied  by  scanty,  loaded  urine,  a  coated 
tongue,  costive  bowels,  and  other  symptoms  of  constitutional 
derangement,  I  have  never  found  it  of  the  slightest  service 
until  after  these  symptoms  have  been  subdued,  and  the  same 
holds  good  in  other  forms  of  muscular  rheumatism.  But  when 
the  pain  has  appeared  referable  to  the  continued  local  eifcct  of 
a  formerly  existing  cause  of  irritation,  or  when  from  the  first 
it  has  been  of  a  purely  local  and  neuralgic  character,  and 
unaccompanied  by  constitutional  disturbance,  then  the  hot  iron 
has  well  sustained  its  character,  and  in  some  instances  has 
afforded  instantaneous  relief.  Indeed,  I  know  of  no  remedy  to 
which  we  can  have  recourse  in  such  cases  with  a  better  pros- 
pect of  relief;  but  I  question  whether  the  instrument  recom- 
mended by  Dr.  Day  is  as  efficacious  as  a  laundress's  small  box- 
iron,  or  one  of  the  irons  used  by  chemists  for  spreading  plaster, 
with  either  of  which  the  limb  may  be  ironed  while  the  skin  is 
covered  with  a  piece  of  brown  paper  or  thin  flannel.  Certain 
it  is  that  in  one  case  in  which  Dr.  Day's  little  button  had  proved 
utterly  useless,  a  common  laundress's  iron  gave  instant  relief, 
a  result  which  I  attributed  to  the  much  larger  surface  subjected 
to  heat  in  the  latter  instance. 

In  striking  contrast  with  this  thermic  mode  of  treatment  is 
the  frigorific  plan  suggested  by  Dr.  James  Arnott.  He  recom- 
mends that  a  freezing  mixture  should  be  applied  to  the  back 
for  the  space  of  four  or  five  minutes,  or  until  complete  anaes- 
thesia of  the  parts  is  produced,  and  he  states  that  in  three  only 
out  of  nine  cases  in  which  he  employed  this  remedy,  was  it 
found  necessary  to  apply  it  a  second  time.^  The  mode  of  using 
this  remedy  is  more  particularly  described  in  my  chapter  on 
Sciatica,  and  it  is  only  necessary  here  to  state  that  the  appli- 
cation, though  somewhat  painful,  and  occasioning  a  degree  of 
1  "  Od  Neuralgic,  Rheumatic,  and  other  painful  Affections,"  p.  29. 


TREATMENT    BY    PARTICULAR    MEDICINES.  377 

redness  or  congestion  which  continues  for  a  few  hours,  or  even 
days  afterward,  according  to  the  duration  of  the  freezing  and 
other  circumstances,  is  not  productive  of  dangerous  results, 
and  may  therefore  be  tried  when  other  and  milder  remedies 
have  failed.  But  it  is  often  looked  upon  with  dread  by  the 
patients,  and  sometimes  occasions  excessive  and  enduring  ten- 
derness of  the  parts  ;  and  therefore  I  would  not  counsel  its 
employment  until  the  catalogue  of  other  remedies  has  been 
exhausted. 

Unfortunately,  I  have  had  so  few  opportunities  of  noting 
its  eiFects,  that  my  testimony  as  to  its  action  is  not  of  much 
value.  In  two  instances  accompanied  by  loaded  urine  and 
constipation,  it  utterly  failed  in  influencing  the  pain ;  in 
another,  which  was  unaccompanied  by  feverish  symptoms, 
immediate  relief  resulted  from  its  application ;  and  in  two 
others  of  a  similar  nature,  relief  was  experienced,  but  a  cure 
was  not  eifected  by  the  first  application,  and  the  patients 
refused  to  submit  to  a  second  trial  of  its  virtues. 

From  such  limited  observations  no  legitimate  inference  is 
fairly  deducible,  but  I  can  readily  conceive  that  where  lumbago 
is  connected  with  a  purely  neuralgic  condition  of  the  superficial 
fasciae  or  the  muscular  structures,  or  even  with  congestion  of 
such  parts  unaccompanied  by  derangement  of  the  secretions, 
the  powerful  influence  of  a  very  low  temperature  may  deaden 
the  sensibility  of  the  nerves,  lull  the  pain,  and  even  put  an  end 
to  the  local  congestion.  But  I  cannot  understand  how  any 
such  agency  can  relieve  the  disease  when  arising,  as  it  often 
does,  in  connection  with  disordered  secretions,  loaded  bowels, 
or  constitutional  derangement;  and  although  I  am  unwilling  to 
rest  my  argument  upon  the  two  unsuccessful  cases  of  this  sort 
above  referred  to,  I  think  it  fair  to  adduce  them  in  support  of 
what  appears  to  be  a  sound  physiological  vicAV.  Experience, 
however,  is  better  than  theory,  however  specious,  and  I  shall 
be  glad  if  further  observation,  or  the  well-attested  experience 
of  others,  enables  me  hereafter  to  modify  my  opinion. 

Of  internal  remedies,    none  prove    more  useful  ^hen    the 
bowels  are  regular,  and  the  urine  is  clear  and  abundant,  than 
25 


378 


CHRONIC    RHEUMATISM. 


Oil  of  Turpentine,  and  few  are  found  less  serviceable  when 
the  bowels  are  costive  and  the  urine  is  high  colored  and  loaded. 
Administered  in  half-drachm  or  two-scruple  doses,  either  in  a 
draught,  or  in  the  form  described  below,'  it  is  an  agent  on 
which  the  greatest  confidence  may  be  placed,  and  case  after 
case  has  been  admitted  under  my  care  at  St.  George's  Hospital, 
in  which  it  has  effected  a  rapid  cure,  after  Guaiacum  and  other 
remedies  had  been  tried  in  vain.  The  only  serious  objection  to 
its  use  is  the  possibility  of  its  giving  rise  to  strangury  and 
nephritic  irritation,  but  if  care  be  taken  in  watching  its  effects, 
no  apprehension  need  be  entertained  on  this  score.  The  mere 
possibility,  however,  of  its  causing  such  symptoms  would,  of 
course,  deter  a  cautious  practitioner  from  recommending  it  to 
a  patient  to  whom  he  was  unable  to  pay  frequent  visits. 

Stiff-neck  is  benefited  by  the  same  sort  of  local  remedies  as 
Lumbago.  Though  in  some  few  instances  leeches  may  be 
needed,  yet  more  generally,  friction,  with  opiate  and  stimulat- 
ing embrocations,  followed  by  warm  fomentations,  to  the  part, 
proves  quite  efficient.  When  the  disease  is  of  recent  occur- 
rence, a  few  drops  of  Chloroform  or  Chloric  ^ther  may  be 
held  to  the  part  in  the  palm  of  the  hand,  until  redness  of  the 
skin  is  produced.  In  several  instances  in  which  the  chloroform 
has  been  so  employed,  the  relief  afforded  has  been  immediate, 
and,  after  two  or  three  applications,  has  remained  permanent ; 
but  when  the  complaint  is  of  long  standing,  friction  is  of  greater 
service. 

The  beneficial  influence  of  baths  is  nowlicre,  perhaps,  dis- 
played more  strikingly  than  in  clironic  rheumatism.  The 
warm  bath,  either  alone  or  rendered  alkaline  by  potash  or  soda, 
the  hot  air  bath,  and  the  vapor  bath  have  each  their  respective 
merits.  The  latter  two  have  always  appeared  to  me  the  most 
efficient  agents  for  forcing  perspiration,  and  relieving  the 
symptoms  in  those  cases  in  which  the  pain  is  aggravated  by 
warmth;    whereas  the  warm  bath,  at  a  temperature  of  at  least 


'  Spiritus  Terebinth  inse, 
Mucilaginis  Acuciae, 
Mellis,  ia  partes  ajquales. 
M.  ft.  Electuarium  cujus  sumatur  cochlearium  unum  Theaj  ter  die. 


BENEFICIAL   EFFECT   OF   LOCAL    REMEDIES.  379 

100°,  has  been  equally  if  not  more  beneficial  to  those  in  whom 
warmth  proves  grateful  and  sedative.  It  must  be  remembered, 
however,  that  the  vapor  and  hot-air  baths  have  the  great  ad- 
vantage of  being  applicable  while  the  patient  is  lying  in  bed, 
and  this,  in  some  instances,  may  be  a  sufficient  recommenda- 
tion to  determine  their  employment  in  preference  to  the  water 
baths. 

In  those  to  whom  cold  does  not  prove  chilling,  and  in  whom 
proper  reaction  ensues  after  the  shock,  the  shower  bath,  more 
especially  of  salt  water,  is  frequently  of  essential  service,  and 
its  good  effects  are  increased  when  reaction  is  maintained  by 
friction.  Local  baths,  as  by  a  douche  of  water,  are  also 
powerful  assistants,  the  more  so  as  they  can  be  employed 
repeatedly,  and  can  be  directed  to  the  immediate  seat  of  pain. 
Should  all  these  fail,  the  mysterious  agency  of  the  Bath,  Ilar- 
roirate,  or  Buxton  waters,  of  the  Wood  Hall  Iodine  and  Bro- 
mine  Spa,  or  of  the  Droitwich  saline  bath,  may  be  resorted  to, 
or  the  patient  may  be  sent  to  some  of  those  continental  thermal 
springs  whose  virtues  were  discussed  in  a  previous  chapter.^ 

Blisters  have  been  recommended,  and  are  frequently  era- 
ployed  for  the  relief  of  chronic  rheumatic  pains,  and,  as  with 
other  remedies,  their  repute  has  varied  according  as  they  have 
been  made  use  of  properly  or  improperly.  In  muscular  rheu- 
matism they  are  seldom  of  much  service,  and  arc  rarely  if  ever 
necessary  ;  and,  in  articular  rheumatism,  are  never  needed, 
unless  the  pain  has  been  long  fixed  in  one  particular  joint,  and 
some  thickening  or  enlargement  has  gradually  taken  place. 
But  in  periosteal  rheumatism  they  are  extremely  serviceable, 
more  especially  when  there  is  thickening;  and  in  rheumatic 
enlargement  of  the  bursse  which  has  passed  into  a  chronic  form, 
they  are  almost  indispensable  for  effecting  a  rapid  cure.  In 
both  these  latter  cases  their  application  should  be  followed  by 
the  external  use  of  iodine.  The  iodine  paint,  which  is  often 
recommended,  is  not  a  good  form  of  application,  except  for  the 
purpose  of  counter-irritation,  inasmuch  as  it  causes  desquama- 
tion of  the  cuticle,  and  thus  by  its  caustic  action  interferes  with 
the  absorption  of  the  remedy.  A  much  more  serviceable  ally 
1  See  Tables,  pages  347  350,  of  this  Treatise. 


380  CHRONIC    RHEUMATISM. 

is  to  be  found  in  the  Compound  Iodine  or  Biniodide  of  Mercury 
ointment,  or  the  iodine  lotion,  the  formuhi  for  which  I  have 
given  elsewhere.^ 

I  have  hitherto  spoken  of  liniments  and  fomentations  as 
applicable  only  to  lumbago  and  other  varieties  of  muscular 
rheumatism.  But  their  efficacy  is  by  no  means  confined  to 
these  cases.  Nothing  proves  more  serviceable  in  old-standing, 
painful  affections  of  the  joints,  than  warm  opiate  fomentations  ; 
and  not  unfrequently  liniments  or  embrocations  prove  equally 
beneficial.  Various  prescriptions  have  been  already  given, 
which,  in  my  hands,  have  proved  exceedingly  efficacious  f  but 
in  this  particular  form  of  disease,  a  liniment,  composed  of  a 
drachm  of  the  essential  oil  of  bitter  almonds  and  fifteen  drachms 
of  almond  oil,  may  be  used  with  the  greatest  benefit.  The 
native  oil  of  laurel,  applied  externally,  was  a  remedy  much  in 
vogue  among  the  North  American  Indians  for  the  cure  of 
rheumatism  and  other  affections  of  the  joints,  and  the  liniment 
now  recommended  possesses  all  its  virtues  in  a  much  higher 
degree.  More  than  once,  pains,  which  had  resisted  all  other 
remedies,  have  yielded  readily  under  its  soothing  influence. 

There  is  yet  another  external  application  well  deserving  of 
a  trial  in  muscular  rheumatism,  which  has  passed  into  a  chronic 
state :  I  mean  an  ointment  containing  Aconitine  or  Veratria. 
That  containing  aconitine  is  far  the  most  powerful  and  efficient. 
So  long  as  the  disease  is  at  all  active  in  its  nature,  I  have  never 
known  benefit  derived  from  its  employment ;  but  its  beneficial 
influence  has  been  so  often  witnessed  when  the  more  urgent 
symptoms  have  been  subdued,  and  the  remaining  pain  has 
appeared  to  be  neuralgic  in  its  nature,  that  no  one  can  doubt 
its  efficacy  in  many  cases  which,  under  other  treatment,  prove 
obstinately  intractable.  It  is  highly  stimulant  and  counter- 
irritant  in  its  action,  and  excites  redness  of  the  skin  wherever 
it  is  applied,  together  with  a  sense  of  tingling  or  pricking.  But 
as  soon  as  this  has  ceased,  its  effect  is  sedative  ;  and,  in  some 
instances,  the  only  interval  of  case  which  the  patient  obtains 
are  the  few  hours  which  immediately  follow  its  employment. 
Sometimes,  from  the  situation  of  the  pain,  it  may  be  difficult, 
1  Note,  p.  326.  ^  Page  374  of  this  Treatise. 


BENEFICIAL    EFFECT    OF    LOCAL    REMEDIES.  381 

if  not  impossible,  to  make  effective  use  of  the  ointment,  and,  in 
such  cases,  Fleming's  Tincture  of  Aconite  or  an  alcoholic  solu- 
tion, formed  by  dissolving  from  three  to  four  grains  of  aconi- 
tine^  in  six  drachms  of  rectified  spirit  and  two  drachms  of 
Glycerin,  and  applied  to  the  part  by  means  of  a  camcl's-hair 
brush,  proves  an  excellent  and  efficient  substitute.  In  inter- 
costal rheumatism  aconitine  proves  remarkably  serviceable,  and 
is  undoubtedly  the  most  valuable  external  remedy  we  possess. 
When  the  fleshy  parts  are  principally  affected,  and  the 
patient  is  unable,  from  the  nature  of  his  pursuits,  to  confine 
himself  any  longer  to  the  house,  it  is  well  to  protect  the  seat  of 
pain  from  cold,  and  to  maintain  a  constant  action  of  the  skin, 
by  the  application  of  flannel  bandages  or  warm  stimulating 
plasters.  In  lumbago  nothing  answers  better  than  a  bandage 
of  oiled  silk  lined  with  flannel,  the  Emplastrum  Arnicas  Mon- 
tanse,^  and  the  Burgundy  pitch  plaster;  and  if  it  be  considered 
desirable  to  inci'ease  the  stimulating  properties  of  the  latter, 
its  surface  may  be  sprinkled  with  hydrochlorate  of  ammonia. 
When  the  joints,  the  tendons,  the  bursae,  or  the  periosteum  are 
aff'ected,  the  Emplastrum  Ammoniaci  c.  Hydrargyro  is  gen- 
erally of  greater  service,  while  in  some  instances  in  which  the 
joints  and  tendons  are  stiff"  and  thickened,  the  Emplastrum 
lodinii,^  spread  upon  wash-leather,  and  applied  closely  round 
the  aff'ected  part,  exerts  a  stimulating  and  softening  influence 
which  is  not  to  be  attained  in  any  other  way.  Again,  when  the 
irritability  of  the  skin  is  such  as  to  preclude  the  use  of  these 
stimulating  plasters,  the  Emplastrum  Opii  may  be  ordered,  or 
warmth  may  be  preserved  by  wrapping  the  part  in  the  finely- 
carded  wool  which  is  known  by  the  title  of  medicated  wool. 
The  rheumatic  patient  is  so  apt  to  suff"er  from  cold  and  atmos- 
pheric vicissitudes,  that  he  should  be  warmly  clad  at  all  times, 
and  not  only  should  the  parts  most  apt  to  suff'er  be  more  than 
ordinarily  protected,  but  his  whole  body  should  be  incased  in 

1  The  aconitine  should  be  obtained  from   Morson,  of  Southampton  Row, 
Bloomsbury. 

2  This   plaster   is  prepared  by    Twinberrow,    of  Edward   Street,   Portman 
Square. 

3  To  be  obtained  at  Ewens's,  106  Jermyn  Street,  St.  James's. 


382  CHRONIC    RHEUMATISM. 

flannel,  or  better  still  in  silk,  and,  in  winter,  covered  with  that 
warm  woolen  clothing  known  linder  the  name  of  fleecy  hosiery. 

Other  expedients  have  been  adopted  occasionally  for  the 
relief  of  old  rheumatic  pains,  among  which  I  may  mention 
electricity,  galvanism,  and  acupuncturation.  In  my  experience, 
however,  they  have  been  rarely  needed,  and  when  needed,  have 
seldom  afforded  material  aid.  The  former  I  have  seen  exten- 
sively employed,  and  have  sometimes  used  it  at  the  instance  of 
m}'  patients  ;  but  so  frequent  has  been  its  failure,  that  in  the 
few  cases  in  which  relief  has  followed  its  use,  I  have  been  in- 
duced to  regard  the  pain  as  of  nervous  origin,  or  its  subsidence 
coincidently  with  the  use  of  electricity  as  a  mere  coincidence. 
Galvanism,  also,  I  have  generally  found  useless,  if,  indeed,  it 
has  not  aggravated  the  pain ;  but  in  some  few  instances  of 
lumbago,  and  in  certain  other  instances,  in  which  the  pain  has 
been  stationary,  and  more  or  less  paroxysmal  in  its  character, 
I  have  witnessed  such  speedy  recovery  after  the  employment 
of  the  continuous  current,  that  I  do  not  hesitate  to  recommend 
its  use  in  obstinate  cases  of  muscular  and  neuralgic  rheumatism. 
In  the  synovial  form  of  the  disease,  I  have  never  known  it  of 
the  least  service. 

Observation  has  not  supplied  me  with  sufiicient  data  for  an 
opinion  as  to  the  efficacy  of  acupuncturation.  On  looking  over 
my  note-books,  I  find  only  five  cases  in  which  I  have  witnessed 
its  application  in  muscular  rheumatism.  In  four  of  these  it 
proved  utterly  useless ;  in  the  fifth  some  amendment  shortly 
followed  its  use,  but  whether  as  the 'result  of  its  employment, 
is  questionable.  Mr.  Churchill,  however,  has  reported  most 
favorably  on  its  curative  powers;*  and  Dr.  Elliotson,  who  "  has 
employed  it  very  extensively,  both  in  private  and  in  St. 
Thomas's  Hospital,  in  rheumatism,"  entirely  confirms  Mr. 
Churehill's  opinion,  and  says,  "it  is  useful  chiefly  in  rheuma- 
tism of  fleshy  parts,  and  the  more  so  as  the  disease  is  less 
inflammatory."^     In  France,  M.  Berlioz^  has  tested  it  largely. 


'  "  A  Treatise  on  Acupuacturalion,"  &c.     London,  1828. 
*  "  Medico  ('liir.  Trans.,"  vol.  xiii. 

'  "  Meinoiies    sur  les  Maladies  Cbroniques,  les  evacuations  sanguines  et 
I'acupuncture."     Paris,  1816. 


INFLUENCE    OF    A    WARM    CLIMATE,    ETC.  B83 

and  speaks  most  higlily  of  its  virtues ;  as  does  also  M.  Jules 
Oloquet,  who  has  recorded  the  history  of  91  cases  in  which  it 
proved  of  the  greatest  service.  I  am  bound,  therefore,  to 
admit,  that  in  some  cases  it  may  prove  eminently  useful ;  but 
I  am  satisfied  by  experience  that  its  application  is  disagreeable, 
that  its  curative  powers  are  uncertain,  and  the  cases  in  which 
it  is  necessary  to  call  them  into  requisition  so  rarely  met  with 
as  to  be  quite  exceptional. 

When  all  remedies  fail,  change  of  air,  if  not  of  climate,  with 
active  exercise,  judicious  bathing,  long-continued  friction,  and 
constant  attention  to  the  state  of  the  skin,  will  often  prove 
effectual  for  our  patient's  relief.  So  long  as  the  effect  of  a  warm 
climate  is  untried,  we  need  never  despair  of  a  radical  cure. 
Even  when  our  best-directed  efforts  have  proved  fruitless,  a  few 
days'  sea  sickness,  followed  by  the  influence  of  genial  warmth, 
a  change  of  scene,  repose  of  mind,  an  altered  diet,  and  a  new 
mode  of  life,  not  unfrequently  prove  successful  in  restoring  a 
hea;lthy  state  of  assimilation,  and  in  stimulating  the  skin,  the 
kidneys,  and  other  excretory  organs  to  the  vigorous  exercise 
of  their  functions.  With  the  stomach  performing  its  duty 
properly,  the  skin  acting  freely  and  regularly,  and  the  liver  and 
kidneys  fulfilling  their  office  of  depurating  agents  efficiently, 
the  rheumatic  poison  cannot  fail  to  be  eliminated,  its  further 
formation  checked,  and  the  system  invigorated.  And  when 
such  is  the  case,  the  rheumatic  pains  will  not  be  long  before  they 
take  their  final  departure.  Many  a  person  who  for  years  had  suf- 
fered from  chronic  rhcum'atism,  has  speedily  got  rid  of  this  in- 
veterate enemy,  by  thus  having  recourse  to  Nature's  assistance 
in  conjunction  with  the  aid  of  judicious  medical  treatment.^ 

1  While  these  sheets  were  passing  throun:h  the  press,  I  met  with  the  follow- 
ing observations  of  my  friend,  Dr.  Dundas,  in  his  recently  published  work, 
entitled  "  Sketches  of  Brazil,"  which  I  quote  in  confirmation  of  the  powerful 
and  salutary  effect  very  often  produced  on  the  organic  functions  by  a  brief 
residence  in  a  warm  climate.  Speaking  of  the  salutary  influence  of  the  sun,  he 
says:  p.  103,  "  Independently  of  direct  physiological  proof,  this  proposition 
will  be  fully  admitted  by  every  tropical  sojourner,  in  whom  years  of  subse- 
quent exhaustion  can  never  entirely  efface  the  recollection  of  the  buoyancy  of 
spirits,  unclouded  mind,  and  exquisite  appreciation  of  mere  animal  existence 
which,  unless  counteracted  by  some  special  influence,  characterize  the  first 
years  of  a  tropical  life." 


CHAPTER  XIII. 

ON    SCIATICA.    AND    OTHER    FORMS    OF    NEURALGIC 
RHEUxMATISM. 

When  rheumatism  attacks  the  nerves  or  their  fibrous  envel- 
opes, it  causes  pain,  which  follows  the  course  of  the  nervous 
trunks,  and  extends  along  their  several  branches.  The  pain 
is  bounded  by  such  narrow  limits,  and  can  be  traced  so  clearly 
following  the  track  of  the  larger  nerves,  that  it  cannot  be  mis- 
taken for  pain  affecting  any  of  the  other  structures.  It  is  often 
someAvliat  paroxysmal  in  its  accession,  and,  though  varying  in 
its  character  in  different  cases,  is  usually  severe  and  very  obsti- 
nate in  its  continuance.  Sometimes  it  is  fugitive,  and  wanders 
from  one  extremity  to  another,  but  more  generally  it  remains 
stationary  in  the  part  first  affected  for  days,  or  weeks,  or  months. 
It  is  frequently  accompanied  by  constitutional  derangement, 
and  is  sometimes  attended  by  fever,  but  more  comnjonly, 
although  the  patient  is  "out  of  sorts,"  the  pulse,  the  tongue, 
and  the  urine  do  not  deviate  greatly  from  the  condition  of 
healtli. 

The  most  remarkable,  as  also  the  most  common  form  of  its 
attack,  is  that  known  by  the  name  Sciatica.  Emerging  from 
the  pelvis  beneath  the  lower  border  of  the  pyriformis  muscle, 
the  sciatic  nerve,  formed  by  branches  from  the  sacral  plexus, 
passes  vertically  down  the  back  of  the  thigh  to  the  ham,  and 
thence,  under  the  name  of  posterior  tibial,  descends  to  supply 
the  leg  and  foot.  This  is  the  nerve  which,  when  irritated  by 
disease,  excites  the  distressing  pain  of  sciatica.  The  pain,  like 
the  nerve,  commences  in  the  loins,  and  shoots  down  the  back  of 
the  thigh  and  leg.  It  is  usually  aggravated  by  damp  and  cold, 
as  also  by  pressure,  and  by  movement  of  the  limb,  and  thus  it 
occurs  with  more  than  ordinary  severity  when  the  patient  goes 


SCIATICA,    NEURALGIC    RHEUMATISM,   ETC.  385 

up  stairs,  or  attempts  to  walk  after  sitting  in  a  cramped  posi- 
tion. In  one  ease  it  is  of  a  dull,  achirig,  or  benumbing  charac- 
ter, and  wearies  by  its  long  continuance  rather  than  by  its 
severity;  in  another  it  exhausts,  not  only  by  its  obstinacy,  but 
by  the  extreme  violence  of  the  startings,  accompanied  by  pains 
of  an  excruciating  nature,  which  occur  at  intervals  throughout 
the  attack ;  while,  in  a  third  class  of  cases,  it  prostrates  all  the 
energies  of  mind  and  body  by  the  continued  indescribable  tor- 
ture which  it  occasions.  The  limb  actually  quivers  with  pain, 
and  the  muscles  are  drawn  ■  into  knots  by  cramp,  and  thus 
afflicted  and  unable  to  move,  the  unhappy  patient  lies  moaning 
during  the  day,  and  dreading  the  approach  of  night,  when  the 
violence  of  the  symptoms  is,  if  possible,  increasexJ. 

Sciatica  is  commonly  met  with  about  the  middle  period  of 
life,  very  few  cases  occurring  before  the  age  of  20,  and  as  few 
after  the  age  of  60.  This  will  be  seen  from  the  subjoined 
tables,*  and  although  there  is  no  reason  why  the  disease  should 
not  occur  at  a  much  earlier,  or  a  much  more  advanced  age,  I 
have  never  chanced  to  encounter  it  before  the  age  of  15  nor 
after  the  age  of  67.  Usually  confined  to  one  side  of  the  body, 
it  sometimes  affects  both  extremities  at  the  same  time,  so  that 
in  14  out  of  103  examples  of  the  disease,  reported  by  Mons. 
Valleix,  the  pain  extended  to  both  extremities,  Avhile  in  46  it 
was  confined  to  the  left  side,  and  in  43  to  the  right.^  In  my 
own  experience  the  simultaneous  affection  of  both  extremities 
has  been  much  more  uncommon,  for  I  have  met  with  it  only  in 
five  instances,  while  in  42  cases  the  pains  attacked  the  right 
side  only,  and  in  28  invaded  the  Icft.^     In  some  other  respects 

1   Collection  of  Cases  cited  by  M.  Valleix.  Authors  Cases. 

Up  to  20  years  of  age.     ...  4  1 

From  20  to  30, 22  10 

"      30  to  40, 30  18 

"      40  to  .50, 3,5  31 

"      50  to  60, 2G  13 

"      60  to  70, 6  2 

Over  70, 1  0 

124  75 

''■  See  Valleix,  "  Traile  des  Ncvralgies,"  p.  503. 
3  These  75  cases  were  well-marked  examples  of  the  disease,  and  do  not  in- 


386  SCIATICA,    AND    OTHER    FORMS    OP 

my  observations  differ  from  those  of  eminent  members  of  our 
profession,  for  no  less  than  61  out  of  my  75  cases  occurred  in 
men,  and  14  only  in  women,  whereas  Dr.  Copland'  gives  it  as 
his  opinion  that  women  are  more  prone  to  its  attacks  than  men. 
In  this  instance,  however,  Mons.  Valleix's  experience  coincides 
with  mine,  for  he  found  as  many  as  72  men^  among  124  patients  . 
affected  with  this  disorder.  It  is  probable  that  my  numbers 
may  shoAV  a  greater  disproportion  between  the  frequency  of 
attacks  in  the  two  sexes  than  is  warranted  by  general  experi- 
ence, inasmuch  as  my  cases,  with  thirteen  exceptions,  occurred 
among  hospital  patients,  in  whose  rank  of  life  the  men,  from 
the  nature  of  their  occupation,  are,  much  more  than  the  women, 
exposed  to  the  exciting  causes  of  the  disease.  Judging,  how- 
ever, from  inquiries  I  have  made  from  various  gentlemen  in 
extensive  practice,  I  am  inclined  to  think,  that  if  hysterical 
affections  and  painful  rheumatism  of  the  muscles  of  the  thigh 
are  excluded  from  the  calculation,  the  proportion  of  attacks  in 
the  two  sexes  will  be  found  to  approach  nearer  to  my  numbers 
than  even  to  those  of  Mons.  Valleix. 

The  disease,  as  already  stated,  is  apt  to  prove  vei-y  obstinate 
in  its  continuance.  Sometimes  it  may  be  subdued  by  appro- 
priate treatment  in  the  course  of  a  few  days,  if  proper  remedies 
be  given  early  and  pushed  vigorously ;  but  if  not  removed  soon 
after  its  invasion,  it  frequently  resists  all  efforts  for  its  expul- 
sion, and  harasses  the  patient  for  weeks  or  months.  Indeed, 
the  limb  may  never  altogether  recover  from  the  attack,  but  may 
waste,  ^nd  remain  for  years,  if  not  for  life,  atrophied,  and  more 
or  less  weak  and  paralyzed.  Three  well-marked  instances  of  this 
sad  result  have  come  under  my  notice  in  hospital  practice.  In 
one  of  these  cases  the  attack  of  sciatica  had  occurred  thirteen 
years,  in  another  eleven  years,  and  in  the  other  five  years  before 
I  saw  the  patient.     In  truth,  sciatica  is  not  itself  a  disease,  but 

elude  any  other  of  the  painful  affections  of  the  hip,  or  muscles  of  the  thigh, 
which  are  often,  but  wrongly,  comprised  under  the  term  sciatica.  This  may 
possibly  account  for  the  discrepancy  observed  between  my  figures  and  the  re- 
corded experience  of  certain  other  observers. 

1  See  ''  Dictionary  of  Medicine." 

*  Loc.  cit.,  p.  5G6. 


NEURALGIC    RHEUMATISM.  387 

rather  is  a  symptom  of  many  diseases.  Thus,  in  some  in- 
stances, it  depends  upon  organic  changes  in  the  nerve  itself, 
or  the  surrounding  structures ;  in  others,  upon  mischief  in  the 
brain  ;  in  others  again,  upon  nephritic  or  gastric  irritation,  or 
upon  irritation  of  the  sacral  plexus  consequent  on  an  unhealthy 
loading  of  the  intestines ;  while  in  another  large  class  of  cases 
it  is  connected  with  constitutional  causes,  each  one  of  which 
produces  a  different  alteration  in  the  condition  of  the  blood, 
and  requires  for  its  removal  a  different  mode  of  treatment. 
And  as  different  affections  have  been  thus  confounded  under 
the  one  title  of  sciatica,  the  cure  in  each  case  is  dependent  on 
the  accuracy  of  the  physician's  diagnosis.  A  remedy  which  is 
suited  for  the  relief  of  a  simple  painful  affection  of  the  nerve 
may  be  useless  to  a  patient  who  is  suffering  from  rheumatic  or 
gouty  irritation,  or  from  inflammation  with  effusion  of  lymph 
and  serum  into  the  sheath  of  the  nerve  ;  while  that,  again, 
which  in  such  a  case  proves  beneficial,  would  probably  exert  no 
curative  influence  when  the  pain  is  dependent  upon  nephritic, 
gastric,  or  intestinal  irritation,  or  upon  local  changes  of  struc- 
ture, either  in  the  nerve  itself  or  in  the  neighboring  parts. 

Thus,  then,  in  every  case  of  sciatica,  three  points  should  be 
accurately  ascertained  before  a  plan  of  treatment  is  decided 
on:  1st,  the  actual  nature  of  the  disease,  whether  it  really  is 
what  it  appears  to  be,  viz.,  a  true  affection  of  the  sciatic  nerve  ; 
2dly,  the  origin  and  cause  of  the  disease  in  the  particular 
instance  before  us ;  3dly,  the  extent  and  character  of  the  mis- 
chief to  be  remedied. 

The  complaints  which  are  most  apt  to  be  mistaken  for  sciatica, 
dependent  on  rheumatic  or  gouty  affection  of  the  nerve,  are 
disease  of  the  hip-joint  and  nephritic  irritation.  Neither  of 
these,  however,  is  likely  to  prove  a  source  of  much  perplexity, 
if  care  be  taken  in  the  examination  of  the  symptoms.  When 
the  former  is  present,  there  certainly  may  be  pain  in  the  affected 
side,  but,  unlike  the  pain  of  sciatica,  it  will  be  increased  when 
the  weight  of  the  body  is  thrown  on  to  the  affected  limb,  as  also 
when  the  head  of  the  bone  is  pushed  upward  against  its  socket, 
while  the  patient  is  lying  on  an  even  surface  in  a  horizontal 


388  SCIATICA,    AND    OTHER    FORMS    OF 

position.  Moreover,  after  a  time  the  disease  is  often  accompanied 
bj  flucti;ation,  more  or  less  perceptible,  giving  rise  to  a  fullness 
in  the  groin,  while  the  constitutional  disturbance  by  which  it  is 
attended  increases  gradually  with  the  progress  of  the  disease. 
By  these  symjitoms  alone  the  distinction  between  the  two  forms 
of  malady  is  made  sufficiently  apparent,  but  it  is  rendered  still 
more  striking  by  the  fact  that,  in  hip  disease,  the  pain  is 
usually  confined  to  the  hip  and  knee  joints,  and  does  not 
extend  to  the  trunk  of  the  sciatic  nerve,  and  even  when  it  does 
so,  is  not  aggravated,  as  in  true  sciatica,  by  pressure  in  the 
course  of  that  nerve. 

Nephritic  irritation  displays  symptoms  equally  peculiar  and 
diagnostic.  If  it  sometimes  causes  spasmodic  pain  shooting 
down  the  thigh  on  the  affected  side,  just  as  in  a  case  of  sciatica, 
it  at  least  gives  perfectly  significant  tokens  of  its  true  source 
and  nature.  It  is  accompanied  by  pain  in  the  course  of  the 
ureters,  and  by  painful  retraction  of  the  testicles,  with  pain 
shooting  down  to  the  tip  of  the  penis,  and  a  frequent  desire  to 
pass  water.  Moreover,  the  urine  is  not  the  clear,  bright  urine 
of  ordinary  sciatica,  but  is  loaded  with  lithates,  or  charged 
with  crystals  of  lithic  acid,  or  oxalate  of  lime.  Thus  it  causes 
many  symptoms  which  sciatica  does  not,  and,  equally  with  hip 
disease,  fails  to  occasion  tenderness  on  pressure  in  the  course 
of  the  sciatic  nerve. 

Having  clearly  ascertained  that  the  disease  is  indeed  sciatica, 
we  must  next  investigate  its  source  and  nature.  Is  it  a  true 
rheumatic  affection  ?  Is  it  connected  Avith  a  syphilitic  taint  V 
Has  gout  any  share  in  its  production  ?  Is  it  caused  by  gastric 
or  intestinal  irritation  ?  Does  it  appear  to  be  of  purely  neu- 
ralgic origin  ?  Is  it  symptomatic  of  mischief  in  the  brain  ?  or 
is  it  dependent  on  the  pressure  of  some  tumor,  or  on  an  alter- 
ation in  the  nerve  itself,  whether  at  its  origin  or  in  some  part 
of  its  course  ?  These  are  indeed  important  questions,  as 
involving  the  rationale  of  the  treatment  to  be  adopted,  and  the 
nature  of  our  prognosis. 

The  two  last-mentioned  causes  of  the  disease  may  be  passed 
over  for  the  present,  as  of  comparatively  rare  occurrence,  and 


NEURALGIC    RHEUMATISM.  389 

as  being  accompanied  by  other  symptoms,  which,  to  the  careful 
observer,  can  hardly  fail  to  afford  some  insight  into  the  source 
and  nature  of  the  existing  mischief.  The  others,  however, 
bear  so  close  a  relation  to  the  treatment  to  be  pursued  in  each 
particular  instance,  that  it  may  be  well  to  examine  more  in 
detail  the  symptoms  by  which  the  operation  of  each  is  denoted. 
Thus,  then,  if  the  patient  is  thin,  pale,  sallow,  and  extremely 
sensitive  to  atmospheric  vicissitudes ;  if  he  has  experienced  pain, 
or  threatenings  of  pain,  in  other  parts  of  the  body ;  if,  at  some 
former  period,  he  has  suffered  from  rheumatism  affecting  the 
joints  ;  and,  above  all,  if  hi^  present  attack  is  the  result  of 
exposure  to  cold  and  damp,  the  disease  under  which  he  is 
laboring  is  rheumatic,  and  is  to  be  relieved  by  vapor  baths, 
guaiacum,  alkalies,  and  similar  remedies.  On  the  other  hand, 
is  he  stout,  florid,  and  a  free  liver,  taking  little  exercise,  and 
sleeping  much,  is  he  plagued  with  heartburn,  acid  eructations, 
and  occasional  lowness  of  spirits,  or  has  he  previously  suffered 
from  gout,  his  malady  is  certainly  of  gouty  origin,  and  is  to  be 
cured  by  colcliicum,  alkalies,  and  alteratives.  Again,  is  he 
cachectic,  and  out  of  health ;  has  his  throat  been  ulcerated,  or 
his  skin  disfigured  by  blotches  or  eruptions ;  has  he  taken  mer- 
cury, or  experienced  pains  in  his  bones,  the  mischief  is  prob- 
ably due  to  a  syphilitic  taint,  and  is  to  be  cured  by  sarsaparilla 
with  iodide  of  potassium.  Or  again,  is  he  robust,  and  usually 
in  the  enjoyment  of  excellent  health  ;  has  his  present  attack 
been  preceded  by  constipation  or  irregularity  of  the  bowels,  by 
flatulent  distention,  and  crampy  pain  in  the  abdomen ;  and, 
above  all,  is  it  accompanied  by  coating  of  the  tongue  and  fetor 
of  the  breath,  then,  if  the  disease  does  not  acknowledge  either 
of  the  origins  .before  alluded  to,  it  is.  probably  due  to  irritation 
of  the  sacral  plexus  of  nerves  consequent  on  an  unhealthy  load- 
ing of  the  intestines.  This  opinion  will  be  confirmed,  if  the 
pain  be  confined  to  the  right  leg,  for  the  disease  not  unfre- 
quently  arises  from  unhealthy  accumulation  of  fajcal  matter  in 
the  caput  coli.  Such  a  case  as  this  is  to  be  cured  by  the 
administration  of  active  purgatives,  both  in  the  form  of  enema 
and  by  the  mouth,  together  with  such  other  medicines  as  are 


390  SCIATICA,    AND    OTHER   FORMS    OP 

calculated  to  carry  off  the  irritating  matter,  and  to  produce  a 
more  healthy  secretion  from  the  bowels.  On  several  occasions 
I  have  known  patients  cured  by  the  administration,  on  three 
successive  nights,  of  two  grains  of  calomel,  two  of  extract  of 
aloes,  and  six  of  scammony,  followed  on  the  morning  of  the 
fourth  day  by  an  enema,  containing  an  ounce  of  castor  oil,  and 
an  ounce  of  spirits  of  turpentine,  or  two  drachms  of  assafetida, 
-or  an  equal  quantity  of  the  confection  of  rue.  In  many  of 
these  cases,  the  action  of  Croton  oil,  as  recommended  by  Mr. 
Hancock,  is  often  of  the  greatest  service.  Again,  if  the  patient 
has  never  experienced  an  attack  of  gout  or  rheumatism,  and 
has  not  suffered  from  wandering  pain  in  the  limbs ;  if  he  is  free 
from  venereal  taint,  and  has  not  been  subjected  to  a  course  of 
mercury  ;  if  his  bowels  have  been  acting  regularly,  and  the 
dejections  are  of  a  healthy  character ;  if  his  skin  is  healthy, 
his  tongue  clean,  his  urine  clear,  the  pulse  normal,  and  the 
appetite  and  digestion  good ;  if,  in  short,  there  is  an  absence 
of  those  symptoms  which  indicate  either  of  the  forms  of 
derangement  hitherto  alluded  to,  his  malady  is  probably  of 
neuralgic  origin,  and  is  to  be  relieved  by  tonics,  sedatives,  and 
other  remedies  directed  against  that  variety  of  derangement. 
On  this  point  our  diagnosis  will  be  greatly  strengthened  if  the 
urine,  when  examined  under  the  microscope,  is  found  to  be 
loaded  with  the  octohedral  crystals  of  oxalate  of  lime. 

Thus,  then,  according  as  one  or  other  of  these  causes  may 
appear  to  have  caused  our  patient's  sufferings,  the  nature  and 
activity  of  the  treatment  must  be  varied.  But  that  is  not  all. 
In  true  sciatica,  from  whatever  cause  arising,  very  different 
local  changes  may  be  induced,  and  very  different  remedies  re- 
quired for  their  relief.  Be  the  affection  rhcumjvtic  or  gouty  in 
its  nature,  or  be  it  due  to  syphilis,  or  to  a  distended  colon,  the 
pain  in  either  case  is  referable  to  a  cause  of  irritation,  which 
may  either  give  rise  to  no  perceptible  local  change,  or  may  be 
accompanied  by  lesions  of  a  more  or  less  serious  nature — from 
simple  congestion  on  the  one  hand,  to  copious  effusion  of  serum, 
or  of  serum  mixed  with  lymph,  within  the  sheath  of  the  nerve. 


NEURALGIC    RHEUMATISM.  391 

or  to  thickening  of  the  sheath  itself,  on  the  other.'  In 
the  former  case,  the  means  already  mentioned  as  adapted  to  the 
removal  of  the  several  causes  from  which  the  affection  derives 
its  origin  will  be  sufficient  to  effect  a  cure.  But,  in  the  latter, 
the  disease  is  more  complex  and  less  tractable.  The  local  con- 
gestion can  seldom  be  relieved  without  the  aid  of  local  rem- 
edies, and  when  the  stage  of  simple  congestion  is  passed,  and 
thickenins:  of  the  sheath  of  the  nerve  has  occurred,  or  effusion 
has  commenced  within  it,  the  use  of  topical  applications  be- 
comes more  than  ever  necessary.  The  effusion  here  is  not,  as 
in  ordinary  rheumatism,  of  secondary  importance  ;  it  gives  rise 
to  pressure  upon  the  nerve,  impairs  its  function,  and  thus  leads 
to  malnutrition  and  wasting  of  the  limb ;  and  if  it  be  not 
speedily  removed,  irremediable  alteration  of  structure  takes 
place,  and  the  nerve,  hardened  by  long-continued  pressure,  is 
found  after  death  gray  and  shrunken. 

In  every  case  of  sciatica,  then,  the  existence  or  non-existence 
of  effusion  within  the  sheath  of  the  nerve,  or  of  thickening  of 
the  sheath  itself,  is  a  question  of  primary  importance.  If  no 
such  mischief  exists,  the  remedies  before  alhuled  to,  as  best 
calculated  to  remove  the  different  causes  of  irritation,  will  be 
the  most  efficient  in  removing  the  irritation,  with  the  pain  and 
other  symptoms  consequent  thereon ;  whereas  if  effusion  or 
thickening  has  already  taken  place,  measures  will  be  needed 
not  only  to  allay  existing  irritation,  and  remove  its  cause,  but 
to  promote  absorption  of  the  effused  fluid,  and  remedy  the  local 
mischief  which  has  occurred. 

By  what  symptoms,  then,  are  we  assured  of  the  existence  of 
effusion  or  of  pressure  on  the  nerve  ?     I  know  not  whether  the 

1  See  •'  Cotunniu3  de  Ischiade  Nervosa  Commentsirius,"  cap.  xxxv,  and  Gen- 
drin's  "  Histoire  Anatomique  de  rinflammation."  The  death  of  a  patient  dur- 
ing the  existence  of  acute  sciatica  is  so  extremely  rare,  and  the  pathological 
effects  of  simple  irritation  and  congestion — the  sole  effects,  I  believe,  of  most 
attacks  of  sciatica— pass  off  so  rapidly,  that  there  are  few  instances  on  record 
in  which  any  lesion  of  the  nerve  has  been  discovered  after  death  This  fact, 
however,  affords  no  argument  against  the  presumption,  which  is  countenanced 
by  strict  physiological  reasoning,  that  when  irritation  and  congestion  pass  on 
to  inflammation,  the  ordinary  results  of  such  action,  namely,  the  effusion  of 
lymph  and  serum,  will  occur  at  the  part  affected. 


392  SCIATICA,    AND    OTHER    FORMS    OF 

experience  of  others  corresponds  with  my  own  observations  on 
this  subject,  but  such  signal  benefit  has  been  often  derived  from 
remedies  applied  in  accordance  with  the  views  I  am  about  to 
enunciate,  that  I  cannot  but  think  them  entitled  to  considera- 
tion. 

At  the  commencement  of  an  attack,  no  certainty  can  be  felt 
as  to  the  existence  of  pressure  on  the  nerve.  But  the  proba- 
bility of  its  occurrence  in  the  course  of  the  disease  is  in  pro- 
portion to  the  severity  of  the  local  symptoms  and  the  intensity 
of  the  febrile  disturbance,  and  remedies  should  be  selected  and 
apportioned  accordingly.  If  pain  be  the  prominent  feature  of 
the  attack,  and  be  unaccompanied  by  febrile  symptoms,  it 
would  be  right  to  act  as  though  no  thickening  or  effusion,  had 
taken  place  ;  whereas,  if  the  pain  be  attended  by  fever,  it 
would  be  prudent  to  have  recourse  to  measures  calculated  to 
check  those  actions  on  which  the  occurrence  of  local  mischief 
depends.  But  after  the  disease  has  lasted  longer  and  has 
passed  into  a  chronic  form,  we  have  more  to  guide  us  to  a  cor- 
rect diagnosis.  If  thickening  or  effusion  be  present,  there  is 
then  not  only  local  pain,  but  numbness  and  partial  paralysis  of 
the  limb  as  the  natural  and  characteristic  results  of  pressure  on 
the  nerve.  The  nerve  being  compressed,  its  function  is  im- 
paired, and  the  symptoms  alluded  to  necessarily  ensue.  Hence, 
when  a  patient  who  is  suffering  from  sciatica  complains  of  a 
dull,  aching,  and  benumbing  pain  in  the  limb,  causing  it  to  feel 
swollen,  when  this  sense  of  numbness  and  increased  bulk  has 
succeeded  to  pain  of  greater  intensity,  accompanied  by  cramps 
and  startings  of  the  limb ;  and  when,  more  especially,  in  addi- 
tion to  these  symptoms,  there  is  more  or  less  inability  to  move 
the  limb,' — inability  arising  from  loss  of  power,  and  not  as  a 

1  In  the  cases  alluded  to,  it  will  be  found  that  the  patients  are  unable  to 
move  the  limb  freely,  even  though  the  pain  be  not  very  severe ;  they  complaia 
that  the  Jimb  is  weak,  and  feels  very  heavy,  and  that  there/ore  they  cannot 
move  it  readily :  nay,  more,  they  will  often  remark,  that  they  have  not  as 
much  power  over  it  as  they  previously  had,  when  the  pain  was  much  more 
severe.  Though  the  first  activity  of  the  inflammation  be  subdued,  the  effused 
matters  which  result  from  that  inflammation  produce  pressure  on  the  uerve, 
impair  its  function,  and  thus  lead  to  loss  of  power  in  the  limb. 


NEUHAL(iIC    RHEUMATISM.  393 

result  of  excessive  pain, — pressure  on  the  nerve  may  be  infer- 
red, and  steps  should  be  taken  to  eflfcct  its  removal  either  by 
mechanical  or  medicinal  means.  In  such  cases  I  have  repeat- 
edly seen  sedatives  employed  freely  and  pertinaciously,  and 
various  antisciatica  remedies  made  use  of  with  the  view  of  ef- 
fecting a  cure ;  but  until  the  measures  alluded  to  have  been 
adopted,  the  failure  has  been  so  uniform  and  so  complete,  that 
now,  whenever  symptoms  of  pressure  present  themselves,  I  al- 
ways resort  to  that  method  of  treatment  which,  whatever  its 
modus  operandi,  is  entitled  to  the  credit  of  giving  speedy 
relief. 

The  measures  which  prove  most  eflBcacious  in  checking  the 
progress  of  the  local  mischief,  and  promoting  absorption  of  the 
matters  effused,  are  cupping,  leeching,  and  blistering,  combined 
with  the  internal  administration  of  mercury,  iodide  of  potas- 
sium, and  diuretics.  The  practice  of  cupping,  leeching,  and 
blistering,  for  the  relief  of  sciatica,  was  first  introduced  by 
Cotunnius,  a  celebrated  Neapolitan  physician,^  under  the  idea 
of  evacuating  an  acrid  humor  from  the  sheath  of  the  nerve  ; 
and  the  comparative  disuse  into  which  it  has  fallen  has  re- 
sulted, I  believe,  from  its  having  been  at  one  time  recklessly 
employed.  It  has  been  often  resorted  to  without  reference  to 
the  question  whether  the  symptoms  denoted  pressure  on  the 
nerve,  and  the  possibility  therefore  of  there  being  fluid  within 
the  sheath  of  the  nerve,  or  thickening  of  the  sheath  itself;  and 
even  in  cases  attended  by  symptoms  indicative  of  pressure,  its 
good  effects  have  been  counteracted  by  unrestrained  movement 
of  the  limb,  and  by  the  exhibition  of  stimulant  and  tonic  med- 
icines, instead  of  mercury,  iodide  of  potassium,  and  other  med- 
icines having  a  tendency  to  promote  the  absorption  of  the  ef- 
fused fluid.  Moreover,  it  was  formerly  the  practice  to  make 
use  of  issues,  rather  than  of  blistering;  and  as  their  only  ef- 
fect was,  as  Dr.  Seymour  remarks,  "  to  add  additional  distress 
to  unrelieved  pain,"  it  is  not  surprising  that  discredit  should 
have  been  thrown  on  this  whole  system  of  treatment.  Em- 
ployed, however,  with  judicious  discrimination,  no  remedies  are 

1  "  Cotunnius  de  Iscliiade  Nervosa  Comnieutahus."     8vo,  Vienna),  1770. 
26 


394  SCIATICA,    AND    OTHER    FORMS    OF 

capable  of  affording  greater  relief.  When  from  the  activity  of 
the  febrile  disturbance,  the  severity  of  the  pain,  and  the  senvse 
of  local  heat  which  attends  it,  it  is  probable  that  the  local  mis- 
chief is  of  recent  date,  even  if  it  be  not  still  going  on,  then 
cupping  or  leeching,  followed  by  blisters  in  the  course  of  the 
nerve,  together  with  mercurials  and  purgative  and  cooling  diu- 
retic medicines,  should  be  resorted  to  early  and  vigorously.^ 
On  the  other  hand,  when  all  febrile  symptoms  have  passed 
away,  when  the  local  mischief  is  of  some  standing,  and  is  prob- 
ably due  to  causes  no  longer  in  existence,  then  mercurial  action 
should  be  slowly  induced  ;  and  blisters  should  be  used  in  pref- 
erence to,  if  not  to  the  exclusion  of,  cupping  and  leeching.  In- 
deed, in  such  cases,  vesication  is,  of  all  local  remedies,  the  most 
important,  and  should  be  steadily  persevered  in,  the  blisters 
being  long  and  narrow,  placed  along  the  track  of  the  nerve, 
and  the  blistered  surface  dressed  with  mercurial  ointment,  or 
sprinkled  daily  with  powdered  morphia,  to  relieve  the  pain.  In 
some  instances,  however,  morphia  applied  in  this  manner  ap- 
pears to  aggravate  rather  than  to  allay  the  pain;  and  when 
such  is  the  case,  its  use  should  be  discontinued. 

There  is  one  local  application  of  singular  efficacy  in  the  cure 
of  sciatica  connected  with  pressure  upon  the  nerve  ;  I  mean  that 
known  as  acupuncturation.  Its  virtue  is  supposed  to  depend 
upon  the  mechanical  assistance  it  affords  toward  the  evacua- 
tion of  fluid  from  the  sheath  of  the  nerve.  While  the  patient 
is  lying  flat  on  his  stomach,  six  or  eight  pairs  of  needles,  spe- 
cially adapted  for  the  purpose,  are  carefully  inserted  into  the 
thigh  along  the  course  of  the  sciatic  nerve,  the  object  being  to 
puncture  the  neurilemma,  and  thus  to  allow  of  the  escape  of 
any  fluid.  The  operation,  if  conducted  slowly,  causes  little  pain 
or  inconvenience,  is  altogether.devoid  of  danger,  and  deserves 
a  trial  in  obstinate  cases.  On  three  occasions  I  have  seen  it 
afford  immediate  relief,  and  in  one  instance  the  relief  was  com- 
plete and  permanent.  In  many  others,  however,  it  has  proved 
unsuccessful :  and  observation  has  led  me  to  believe,  that  the 
•  difference  in  the  result  has  been  attributable,  in  some  instances, 
1  See  Case  II,  appended  to  this  chapter. 


NEURALGIC    RHEUMATISM.  395 

to  imperfect  manipulation,  whereby  the  sheath  of  the  nerve  has 
escaped  unpunctured,  and  in  some,  to  the  widely  differing  cir- 
cumstances under  which  the  operation  has  been  undertaken. 
If  resorted  to  when  no  effusion  exists,  or  while  any  trace  of 
inflammation  remains,  it  cannot  be  useful,  and  is  found  not  to 
be  so  in  practice.^  Indeed,  in  the  latter  case,  it  often  acta 
prejudicially ;  whereas,  if  employed  when  inflammation  has 
subsided,  and  the  nerve  is  irritated  by  the  unwonted  pressure 
of  the  effused  fluid,  it  promises  speedy  and  effectual  relief. 

It  is  not  to  be  supposed,- however,  that  in  all  cases  of  scia- 
tica, or  indeed  in  the  major  part  of  them,  effusion  takes  place 
into  the  sheath  of  the  nerve.  The  symptoms  by  which  that 
lesion  is  accompanied  are  very  striking,  and  by  no  means  of 
common  occurrence.  In  most  instances  of  sciatica  the  pain  is 
obviously  unconnected  with  pressure  on  the  nerve,  and  arises 
either  from  its  sympathy  with  irritation  in  the  intestinal  canal 
or  some  other  distant  part  of  the  body,  or  else  from  irritation 
and  congestion  of  the  nerve  itself  consequent  on  the  presence 
of  some  morbid  matter  in  the  blood.  In  the  former  cases  the 
cause  of  irritation  must  be  removed  before  any  alleviation  of 
pain  can  be  expected ;  in  the  latter,  counter-irritation  and  seda- 
tives, combined  with  such  medicines  as  will  neutralize  or  elim- 
inate the  peccant  matter,  will  generally  afford  relief.  But  in 
neither  will  acupuncturation  or  the  remedies  already  spoken  of 
as  calculated  to  produce  absorption,  have  the  slightest  influence 
on  the  progress  of  the  disease. 

Of  all  internal  remedies,  those  which  come  most  generally 
and  most  beneficially  to  our  aid  are  sedatives,  with  opium  and 
belladonna  at  their  head.  Opium,  with  the  various  salts  of 
morphia;  belladonna,  given  internally  and  applied  externally, — 
henbane,  conium  and  stramonium,  the  cannabis  indica,  digitalis, 
aconite  and  veratria,  these  are  among  the  most  powerful  and 
most  efl^icient  of  our  allies.  In  purely  neuralgic  cases  they 
appear  to  act  as  directly  curative  agents,  and  require  little  aid 

1  In  this  statement  I  am  borne  out  by  Dr.  EUiotson,  who  says,  "  I  have  never 
seen  it  beneficial  in  any  inflammation  or  inflammatory  pain."  ("  iMedico-Chir. 
Trans.") 


396  SCIATICA,    AND    OTHER    FORMS    OF 

in  effecting  our  object,  while  even  in  other  forms  of  sciatica 
they  prove  most  valuable  in  mitigating  the  severity  of  the  pain. 
But  in  true  rheumatic  or  gouty  cases  this  class  of  remedies, 
with  the  exception,  perhaps,  of  aconite,  veratria,  and  digitalis, 
appears  to  be  of  service  only  in  so  far  as  they  tend  to  diminish 
nervous  irritability,  and  procure  repose.  Their  value  seems  to 
depend  upon  their  power  of  temporarily  assuaging  pain  and 
producing  sleep,  more  than  upon  the  exercise  of  any  curative 
influence.  They  put  a  stop  to  that  irritability  which  would 
otherwise  render  futile  all  efforts  to  improve  the  general  health 
of  our  patient,  and  to  prevent  the  further  generation  of  the 
rheumatic  poison  ;  and,  moreover,  after  the  cause  of  the  disease 
has  been  got  rid  of,  they  enable  the  patient  to  endure  its  painful 
consequences  during  the  period  required  for  their  removal. 

Two  points,  therefore,  present  themselves  for  consideration 
before  commencing  the  administration  of  this  class  of  medicines ; 
first,  what  sedative  is  likely  to  prove  most  beneficial  in  the 
particular  instance  before  us  ?  and,  secondly,  in  what  doses 
will  it  be  needed  ?  To  neither  of  these  questions  can  a  definite 
answer  be  returned.  The  particular  sedative  to  be  employed 
must  be  regulated  in  part  by  the  idiosyncrasy  of  the  patient, 
by  the  form  which  the  disease  has  assumed,  and  by  the  stage 
at  which  it  has  arrived  ;  and  the  quantity  of  the  sedative 
required  can  only  be  measured  by  the  influence  exerted  over 
the  intensity  of  the  pain.  In  many  cases  opium  and  the  salts 
of  morphia  afford  us  all  the  assistance  we  desire ;  but  in  some 
they  disagree,  or  unless  administered  in  very  large  quantities, 
arc  practically  inoperative  for  good.  It  then  becomes  expe- 
dient to  have  recourse  to  some  other  substances  of  the  same 
class,  and  belladonna,  stramonium,  hyoscyamus,  coniura,  or  the 
cannabis  indica,  may  be  employed  as  occasion  requires.  Bella- 
donna is  especially  useful  in  those  cases  which  are  marked  by 
spasmodic  twitchings  of  the  muscles,  whether  manifested  by 
cramp,  or  by  starting  of  the  limb  ;  and  from  a  quarter  to  a 
third,  or  even  two-thirds  of  a  grain  of  the  extract  may  be  safely 
administered  twice  or  three  times  a  day.  It  is  apt,  however, 
to  produce  dryness  of  the  fauces,  together  with  vertigo,  and 


NEURALGIC    RHEUMATISM.  397 

excessive  depression  of  the  vital  powers.  It  should,  therefore, 
be  employed  with  extreme  caution,  the  patient  being  watched 
throuo^hout  the  period  of  its  administration  in  order  that,  at  the 
least  dilatation  of  the  pupil,  or  at  the  occurrence  of  headache 
with  confusion  of  thought,  the  use  of  the  remedy  may  be  at  once 
abandoned. 

But  it  is  not  only  from  its  internal  administration  that  benefit 
may  be  obtained  in  these  cases  ;  the  greatest  advantage  is  some- 
times derived  from  its  direct  application  to  the  seat  of  pain, 
both  in  the  form  of  plaster  and  in  that  of  fomentation.  Not 
unfrequently  an  admixture  of  belladonna  and  opium  may  be 
advantageously  prescribed,  in  the  proportion  of  one  drachm  of 
the  extract  of  belladonna  to  an  ounce  of  laudanum  and  three 
drachms  of  glycerin.  A  piece  of  lint  wetted  with  this  mixture, 
and  covered  with  oiled  silk,  often  affords  very  great  relief  when 
placed  along  the  course  of  the  nerve.  But  in  whatever  form 
the  remedy  is  applied,  it  certainly  exerts  a  remarkable  influence 
over  the  violence  and  duration  of  the  spasms  ;  and  the  only 
point  to  be  borne  in  mind  is,  that  it  must  not  be  used,  even  in 
the  endermic  method,  without  much  caution.  For  if  an  over- 
large  quantity  be  employed,  or  a  slight  abrasion  exist  in  the 
cuticle,  so  that  absorption  takes  place  rapidly,  it  is  apt  to  pro- 
duce excessive  dryness  of  the  fauces,  with  giddiness,  dimness 
of  vision,  and  other  early  symptoms  of  narcotic  poisoning. 

Stramonium,  which  was  first  recommended  by  the  late  Dr. 
Marcet,  has  been  employed  largely  in  the  cure  of  this  disease, 
but  not,  as  far  as  my  experience  has  gone,  with  any  great  suc- 
cess. In  some  cases,  where  the  symptoms  shift  from  limb  to 
limb,  and  probably  are  more  strictly  nervous  than  rheumatic, 
the  extract  produces  a  decidedly  good  effect ;  but  in  no  single 
instance  in  which  the  disease  has  been  obstinately  stationary, 
have  I  known  it  exercise  any  control  over  the  violence  or 
duration  of  the  symptoms.  Administered  in  doses  of  from  one 
to  two  grains,  its  operation  is  sometimes  remarkably  sedative, 
but  more  generally  its  action  is  uncertain,  and  is  accompanied 
now  and  then  by  excessive  dryness  of  the  throat  and  fauces. 

The    hyoscyamus'  niger   and   the   conium   maculatum    yield 


398  SCIATICA,    AND    OTHER   FORMS    OF 

tinctures  and  extracts  possessing  sedative  qualities  well  adapted 
for  the  relief  of  this  painful  disease,  but  not  possessing,  as  far 
as  I  am  aware,  any  obvious  superiority  over  those  already 
described.  They  are  certainly  milder  and  more  manageable 
medicines  ;  and  as  they  are  often  tolerated  by  the  system  when 
opium  and  belladonna  disagree,  they  may,  and  do  sometimes, 
prove  serviceable.  But  in  proportion  as  they  are  milder  than 
the  aforesaid  anodynes,  so  also,  in  most  instances,  they  are 
inferior  in  allaying  pain  and  calming  the  irritation  consequent 
thereon,  and  their  use,  therefore,  should  be  reserved  for  those 
cases  in  which  there  is  something  to  contraindicate  the  employ- 
ment of  those  which  are  more  powerful  and  more  efficient. 

The  cannabis  indica  may  be  administered  in  the  form  either 
of  extract  or  tincture,  but  the  latter  has  appeared  to  me  the 
most  speedy  and  certain  in  its  operation.  Given  in  doses  of 
from  twelve  to  twenty  minims,  it  has  often  allayed  pain  and 
produced  repose  after  most  of  the  ordinary  sedatives  have 
failed.  Its  action,  however,  is  rather  capricious.  In  some 
instances  it  proves  anodyne  and  narcotic  in  the  highest  degree  ; 
in  others  its  action,  though  marked  by  relief  from  pain,  is  not 
accompanied  by  true  sleep,  but  rather  by  a  happy  semi-con- 
scious dreamy  state  ;  while  in  others,  again,  it  fails  entirely  in 
exercising  any  anodyne  influence,  and  is  apt  to  stimulate  and 
produce  an  effect  resembling  the  excitement  of  intoxication.  In 
one  patient  who  by  mistake  took  double  the  dose  I  had  ordered 
this  effect  was  most  remarkable  and  distressing.  Much  caution 
therefore  must  be  observed  in  selecting  proper  cases  for  its 
exhibition,  and  on  no  pretext  should  a  full  dose  be  given  until 
the  patient's  susceptibility  to  its  influence  has  been  thoroughly 
gauged. 

There  is  one  mode  of  employing  morphia  and  other  narcotics 
which  deserves  special  notice,  as  enabling  us  to  afford  imme- 
diate, though  too  often  temporary,  relief  from  suffering.  I 
allude  to  the  injection  of  a  concentrated  solution  of  the  drug 
into  the  cellular  tissue  of  the  body.  Formerly  this  practice  was 
unsatisfactory  in  its  results,  in  consequence  of  the  clumsiness 
of  the  means  employed  ;  but,  of  late  years,  the  improvement  in 


NEURALGIC    RHEUMATISM.  399 

surgical  appliances  has  led  to  its  revival.  Indeed,  as  now  em- 
ployed, it  promises  to  be  of  great  utility.  A  small  glass  syringe, 
with  a  fine  perforated  needl^like  nozzle,  has  been  manufac- 
tured, which  renders  the  injection  of  the  solution  easy,  and 
almost  painless,  while  at  the  same  time  the  operator  is  enabled 
to  calculate  to  a  nicety  the  amount  of  fluid  injected.^ 

At  St.  George's  Hospital  this  method  of  treatment  has  been 
had  recourse  to  in  a  considerable  number  of  cases,  and  with 
tolerably  satisfactory  results.  If  the  disease  has  not  been 
cured  through  its  agency,  the  pain  at  least  has  been  relieved, 
and  temporary  repose  obtained.  In  every  instance,  as  far  as 
I  am  aware,  morphia  has  been  the  drug  made  use  of;  and 
usually  its  full  effect  has  been  produced,  and  sleep  has  resulted, 
within  ten  minutes  from  the  first  commencement  of  the  injec- 
tion. Nay  more,  on  several  occasions,  the  repetition  of  the 
operation  on  three  or  four  successive  days  has  been  followed 
by  complete  and  permanent  cessation  of  pain.^  In  many 
instances,  however,  this  has  not  been  the  case ;  and  my  impres- 
sion is,  that  although  the  palliative  effects  of  this  treatment 
may  be  produced  in  all  cases  of  sciatica,  yet  that  sedative 
injections  do  not  exercise  a  curative  effect,  except  in  cases 
where  the  pain  is  of  a  purely  neuralgic  character,  unconnected 
with  local  organic  lesion,  or  Avith  irritation  in  distant  parts  of 
the  body.  In  short,  their  curative  effects  are  manifest  in  the 
same  class  of  cases  as  are  benefited  by  morphia,  applied  to  a 
blistered  surface  as  before  recommended.^  The  great  advant- 
age which  the  injection  of  morphia  possesses  over  the  applica- 
tion of  the  dru2  to  a  surface  denuded  of  cuticle  is  the 
painlessness  of  its  application,  and  the  speediness  of  its  action  : 
the  disadvantage  is  the  power  and  consequent  danger  of  the 
remedy  when  thus  administered.  The  full  dose  is  absorbed, 
and  produces  its  narcotic  effect  at  once ;  whereas,  when  taken 
into  the  stomach,  it  is  mixed  with  the  various  ingesta,  finds  its 

1  This  instrument  is  manufactured  by  Messrs.  Whiclier  and  Blaise,  of  tit. 
James's  Street,  S.  W. 

2  See  Case  VI  appended  to  this  chapter. 
5  At  p.  394  of  this  treatise. 


400  SCIATICA,    AND    OTHER    FORMS    OF 

■way  into  the  veins  by  slow  degrees,  and,  probably,  is  in  part 
decomposed  in  the  stomach,  and  in  part  carried  out  of  the 
system  by  the  bowels,  without  hiving  entered  the  circulation. 
Be  this  as  it  may,  the  effects  of  its  injection  are  so  powerful  and 
so  speedily  pro<luced,  that  I  would  earnestly  counsel  those  who 
have  recourse  to  its  assistance,  not  to  inject  above  a  quarter  or 
half  a  grain  in  the  first  instance,  and  to  allow  at  least  six  hours 
to  elapse  before  the  operation  is  repeated.  I  have  never 
known,  nor  have  I  ever  heard,  of  mischief  being  produced  by 
the  remedy  when  thus  cautiously  employed,  and  I  have  seen  it 
produce  effects  as  satisfactory  as  they  were  astounding.  The 
agonized  sufferer,  who  for  many  days  and  nights  in  succession 
has  been  unable  to  close  his  eyes,  or  obtain  a  moment  of  repose, 
notwithstanding  the  internal  administration  of  morphia  in  large 
doses,  has  fallen  into  a  calm  sleep  within  a  few  minutes  after 
the  injection  has  been  commenced. 

Dr.  Alexander  Wood,  of  Edinburgh,  recommends'  that  an 
examination  be  made  to  ascertain  the  spot  at  which  the  pain 
is  felt  most  acutely,  and  that  the  sedative  be  always  injected 
at  the  painful  spot.  But  our  experience  at  St.  George's  Hos- 
pital is  opposed  to  this  plan  of  proceeding,  inasmuch  as  it  ap- 
pears that  the  frequent  introduction  of  a  perforated  needle,  and 
the  injection  of  fluid  at  the  same  spot,  is  apt  to  lead  to  inflam- 
mation and  the  formation  of  abscess — a  result  which  may  be 
avoided  if  the  needle  is  introduced  on  each  occasion  into  a  dif- 
ferent part  of  the  affected  limb.  Moreover,  there  is  not  any 
practical  reason  why  the  injection  should  be  performed  at  the 
most  painful  spot ;  for  our  late  house-surgeon,  Mr.  Hunter,  who, 
in  the  wards  of  St.  George's  Hospital,  was  one  of  the  first  in 
London  to  carry  out  the  principle  of  Dr.  Wood's  practice, 
ascertained  distinctly  that  it  matters  not,  in  the  slightest  de- 
gree, at  what  part  of  the  body  the  injection  is  effected.  The 
only  requisites  for  obtaining  s.afe  and  satisfactory  results  are  : 
1st,  that  a  proper  instrument  be  employed ;  2d,  that  a  concen- 
trated solution  of  morphia  be  used,  so  that  the  cellular  tissue 
be  not  unduly  disturbed  by  the  injection  of  a  large  quantity  of 
'  See  "Assoc.  Journ.,"  Aug.  28,  1858. 


NEURALGIC    RIIEUxMATISM.  401 

fluid ;'  3d,  that  the  dose  be  sufficiently  large  to  give  relief  from 
suffering,  but  not  large  enough  to  produce  toxical  effects  ;  and 
4th,  that  the  injection  be  not  repeated  at  the  same  spot.  With 
these  precautions,  the  remedy  is  one  which  may  be  resorted  to 
advantageously^  whenever  the  pain  of  sciatica  is  very  acute  and 
persistent,  and  resists  the  action  of  drugs  as  ordinarily  em- 
ployed. 

Digitalis  is  a  remedy  almost  unknown  to  the  profession^  as 
exercising  a  curative  influence  on  this  disease,  but  is  one,  never- 
theless, on  which  much  reliance  may  be  placed  when  the  pain 
is  intermittent,  and  purely  of  a  neuralgic  character.  Sedative 
and  diuretic  in  its  action,  it  calms  the  vascular  system  and 
excites  an  increased  flow  of  urine,  and  thus,  though  not  exer- 
cising a  narcotic  influence,  it  frequently  allays  pain  and  affords 
repose.  But  its  curative  effects  are  only  displayed  in  the  class 
of  cases  above  alluded  to.  If  the  system  be  charged  with  the 
rheumatic,  gouty,  or  syphilitic  poison ;  or  if  the  pain  be  con- 
nected with  local  inflammation,  or  with  costive  bowels  and  intes- 
tinal irritation,  digitalis  will  be  found  of  little  or  no  avail.  In 
appropriate  cases,  however,  a  grain  or  a  grain  and  a  half  of  the 
powdered  leaves,  or  from  ten  to  twenty  minims  of  the  tincture, 
repeated  three  or  four  times  a  day,  will  be  found  a  very  valu- 
able remedy. 

The  veratrum  album  is  another  remedy  which  has  been  em- 
ployed in  certain  forms  of  sciatica.  Closely  related  to  the 
colchicum  autuninale,  it  was  recommended  by  Mr.  Moorc^  as 
long  ago  as  1811,  as  a  substitute  for  the  celebrated  Eau  Mddi- 
cinale  of  the  Chevalier  D'Husson.  Since  that  time  it  has  been 
administered  occasionally  in  every  species  of  gouty  or  rheumatic 
affection  in  which  colchicum  is  ever  used,  and  has  been  specially 

1  The  solution  usually  employed  at  St.  George's  contains  ten  grains  of  the 
Acetate  of  Morphia  to  one  drachm  of  distilled  water;  but  I  prefer  a  solution  of 
five  grains  to  the  drachm,  inasmuch  as  the  salt  is  more  readily  soluble  in  this 
proportion,  while  the  quantity  of  the  liquid  which  it  is  requisite  to  inject  is 
not  large  enough  to  excite  local  irritation. 

*  The  only  notice  I  can  find  of  the  antineuralgic  property  of  digitalis  i«  con- 
tained inrfi  brief  communication  from  Mr.  Hardwicke,  of  Rotherham,  inserted 
in  the  'Assoc.  Med.  Journal"  for  June  1,  1855. 

^  See  "Two  Letters  to  Dr.  Jones." 


402  SCIATICA,    AND    OTHER    FORMS    OF 

recommended  in  the  neuralgic  forms  of  the  disease.  Given 
internally  in  small  and  repeated  doses,  it  is  said  to  excite  cuta- 
neous exhalation,  to  increase  the  action  of  the  kidneys,  and  to 
promote  secretion  from  all  the  mucous  surfaces.  Of  its  inter- 
nal administration,  however,  I  have  had  a  ver^  limited  expe- 
rience, having  watched  its  effects  only  in  some  few  cases  in 
hospital  practice,  and,  up  to  the  present  time,  my  observation 
has  not  led  me  to  form  a  very  favorable  estimate  of  its  virtues. 
Whether  owing  to  imperfection  in  the  preparation  employed, 
or  to  some  other  cause  which  may  influence  its  operation,  the 
effects  which  have  been  attributed  to  it  have  not  ensued.  In 
one  or  two  instances  some  improvement  has  taken  place  after 
a  dose  of  from  five  to  fifteen  minims  of  the  Tinctura  Veratri, 
administered  two  or  three  times  a  day.  But  more  generally 
the  disease  has  progressed  uninfluenced  by  its  action,  and  it 
has  appeared  to  me  questionable  Avhether  the  improvement 
which  took  place  in  the  cases  alluded  to  was  really  attributable 
to  the  agency  of  the  remedy.  I  have  no  experience  of  the 
internal  administration  of  the  alkaloid  veratria,  but  it  has  been 
given  internally  by  Sir  James  Bardsley,  who  says  it  possesses 
"no  particular  claims  to  the  attention  of  the  profession." 

The  preparations  of  the  Aconitum  Napellus,  whether  taken 
internally  or  employed  externally,  arc  much  mjre  efficient 
remedies  in  sciatica.  I  have  already^  pointed  out  the  class  of 
cases  in  which  I  have  found  aconite  most  serviceable,  and  I 
may  add,  that  although  the  extract  has  been  recommended  as 
a  convenient  form  for  its  administration,  I  have  invariably  pre- 
scribed the  tincture,  under  the  belief  that  it  is  not  only  more 
certain  in  its  action,  but  is  a  safer  form  for  the  exhibition  of 
the  remedy.  During  the  last  eight  years  I  have  tested  its  value 
in  twenty-five  well-marked  cases  of  sciatica,  of  which  nine  were 
characterized  by  symptoms  of  active  disease,  and  sixteen  were 
examples  of  the  disease  in  its  chronic  or  subacute  form.  In 
one  only  of  the  first-named  class  of  cases  did  it  appear  to  exer 
cise  the  slightest  control  over  the  symptoms,  but  in  five  of  the 
chronic  cases  it  afforded  almost  immediate   relief,  and  "the  pa- 

1  See  p.  371. 


NEURALGIC    RHEUMATISM.  403 

tients  recovered  perfectly  under  its  continued  use,  wliile  in 
severiil  others  decided  improvement  followed  its  administration. 
In  no  single  instance  did  the  slightest  inconvenience  result  from 
its  action,  and,  therefore,  I  think  we  are  justified  in  concluding, 
not  onl)'  that  it  proves  a  valuable  and  eflScient  remedy  in  many 
obstinate  forms  of  the  disease,  but  that,  if  properly  adminis- 
tered^ and  carefully  watched,  it  is  as  safe  and  manageable  as 
any  other  medicine.  The  risk,  however,  incurred  by  the  care- 
less exhibition  of  aconite  and  veratria  is  on  all  hands  admitted 
to  be  so  considerable,  that  I  never  have  recourse  to  their  inter- 
nal administration  unless  I  have  frequent  opportunities  of  seeing 
the  patient.  Externally  they  may  be  employed  more  frequently, 
as  in  this  form  no  risk  is  incurred,  and  their  beneficial  influence 
is  often  strikingly  displayed.  More  than  once  the  tincture  of 
the  roots,  or  an  acidulated  solution  of  the  alcoholic  extract,^  or 
alcoholic  solutions  of  the  alkaloids  aconitine  and  veratria,  ap- 
plied by  means  of  a  camel's-hair  brush,^or  ointments  containing 
aconitina  and  veratria,*  rubbed  night  and  morning  along  the 
course  of  the  affected  nerve,  have  afforded  relief  after  every 
other  remedy  had  been  tried  in  vain ;  and  in  no  single  instance 
within  my  experience  have  they  given  rise  to  the  slightest  in- 
convenience. Very  different  results,  however,  have  attended 
their  use  in  different  cases.     On  no  occasion  in  which  they  have 

1  See  p.  372. 

2  The  alcoholic  extract  of  aconite,  to  be  obtained  at  Bell's,  in  Oxford  street, 
is  an  excellent  preparation.  It  is  far  cheaper  than  pure  aconitine;  and  in  the 
proportion  of  from  ten  to  twenty  grains  to  an  ounce  of  spirits,  slightly  acidu- 
lated with  sulphuric  acid,  it  is,  I  believe,  almost  as  efficacious. 

5  The  formula}  I  usually  employ  are,  for  the  alcoholic  solutions: 

Aconitinae,  gr.  vj  ;  Or,  Veralria;,  gr.  xx-xxx. 

Spir.  Redificati,  5^j  j 

(jtlycerini,  3ij-     Misce. 
These  alkaloids  should  be  obtained  at  Morsou's,   of  Southampton    Row, 
Bloomsbury.     Care  must  be  taken   not   to   employ  them  where  the  skin   is 
abraded. 

*  For  the  ointments: 

Aconitina;,  gr.  x-xv;  Or,  Veratria;,  gr.  xxxvj. 

Adipis  preparatae,  "^v'l] ; 

Olei  Oliva;,  3j ; 

Olei  Bergamotti,  Tl^x  ; 

Olei  Sautalie,  TTl^ij.     Misce. 


404  SCIATICA,    AND    OTHER    FORMS    OF 

been  tried  during  the  active  or  inflammatory  stage  of  the  disease, 
have  they  exercised  the  slightest  influence  for  good  ;  nor  have  1 
seen  much  benefit  result  from  their  employment  so  long  as  the 
patient  has  exhibited  other  symptoms  of  gout  or  rheumatism; 
but  in  obstinate  neuralgic  cases,  unattended  by  febrile  disturb- 
ance, their  curative  power  has  been  exerted  very  conspicuously. 

There  is  no  class  of  remedies  about  the  efficacy  of  which,  in 
the  cure  of  sciatica,  a  greater  difference  of  opinion  exists  than 
about  counter-irritants.  Dr.  Macculloch^  and  others  consider 
blisters  positively  injurious  when  applied  directly  to  the  painful 
part,  while  a  large  proportion  of  the  profession  in  this  country 
and  on  the  Continent  regard  them  as  among  the  most  valuable 
of  remedial  agents.  The  truth  appears  to  be,  that  in  propor- 
tion as  the  complaint  is  purely  neuralgic,  arising  from  irritation 
at  a  distance  from  the  seat  of  pain,  and  is  independent  of  local 
congestion,  so  are  blisters  and  counter-irritants  of  less  and  less 
value,  and  that  their  efficacy  becomes  apparent  only  when  there 
exists  some  local  mischief  which  their  action  modifies  or  sub- 
dues. Whatever  may  be  urged  against  the  indiscriminate  use 
of  blisters,  there  cannot  be  a  doubt  that  when,  in  proper  cases, 
a  number  of  them  are  applied  in  succession,  whether  in  strips 
along  the  whole  course  of  the  nerve,  or  at  those  points  only 
which  are  painful  on  pressure,  as  recommended  by  M.  Valleix,^ 
the  effect  produced  is  often  satisfactory.  The  pain  is  not  only 
temporarily  relieved,  but  the  disease  is  permanently  arrested. 
The  application  of  blisters,  however,  is  at  all  times  a  painful 
and  disagreeable  proceeding :  and  in  sciatica  at  least,  though 
sometimes  successful,  is  at  best  a  very  uncertain  remedy. 
Therefore,  as  we  possess  many  other  means  of  counter-irrita- 
tion of  almost  equal  efficacy,  and  far  less  painful  in  their  appli- 
cation, I  rarely  have  recourse  to  vesication  by  the  Spanish  fly, 
when  my  object  is  simply  to  produce  counter-irritation. 

Some  persons,  however,  have  not  hesitated  to  employ  reme- 
dies of  a  still  more  painful  and  heroic  nature.  Thus,  the  actual 
cautery,  first  recommended  by  Paulus  iEgineta,  and  employed 

1  "  Ou  Marsh  Fever  and  Neuralgia." 

2  "  Traite  des  Neuralsries." 


NEURALGIC    RHEUMATISM.  405 

in  several  instances  by  Cotunnius,  has  been  resorted  to  of  late 
years  by  several  practitioners  on  the  Continent.  M.  Jobert 
especially,  by  his  practice  at  the  H6pital  Saint-Louis,  has  given 
his  sanction  to  the  use  of  the  red-hot  iron,  after  the  manner 
recommended  by  Dr.  Day,  in  his  notes  on  the  so-called  thermic 
treatment.  Whatever  the  relief  aflforded  by  its  application,  the 
remedy  is  so  painful  and  so  fearfully  alarming,  that  I  question 
whether  any  circumstances  would  induce  me  to  recommend  it. 

Moxas  are  another  form  of  local  application  highly  spoken 
of,  and  not  unfrequently  used  in  obstinate  cases ;  but,  as  M. 
Valleix^  very  shrewdly  remarks,  their  action  is  much  the  same 
as  that  of  blisters  and  the  actual  cautery,  but  is  far  more  pain- 
ful than  the  one,  and  slower  and  less  efficacious  than  the 
other. 

One  of  the  readiest  and  most  efficient  methods  of  applying 
counter-irritation  is  by  means  of  a  small^^iron,  heated  by  hot 
water  after  the  manner  described  at  p.  375.  It  possesses  this 
advantage  over  every  other  local  remedy,  that  its  action  is 
immediate,  and  can  be  regulated  so  as  to  produce  slight  rube- 
faction  of  the  part,  or  to  raise  the  cuticle  in  vesication.  But 
when  it  is  desired  to  pass  beyond  the  bounds  of  mere  rubefac- 
tion,  nothing  proves  more  efficacious  than  the  strong  Liquor 
Ammoniae,  ap])lied  on  a  pledget  of  lint  or  a  bit  of  cotton-wool, 
and  covered  with  a  glass.  Rubefaction  is  almost  instantly 
produced,  and  in  a  few  seconds  a  blister  will  be  raised.  By 
this  means  I  have  known  relief  afforded  on  two  occasions  after 
several  other  counter-irritants  had  failed. 

The  tartar  emetic  ointment,  an  ointment  containing  croton 
oil,  or  the  biniodide  of  mercury  in  the  proportion  of  two  scru- 
ples or  a  drachm  to  an  ounce  of  lard,^  and  various  stimulating 
liniments^  have  been  employed  as  counter-irritants  in  these 
cases,  and  have  been  praised  as  possessing  extraordinary  effi- 
cacy. But  the  obstinacy  and  excessive  pain  and  discomfort  of 
the  cutaneous  eruption  they  occasion  is  more  than  sufficient 

1  Loc.  cit.,  p.  625. 

2  "  Cast's  of  Tic  Doloreux,"  by  John  Scott. 

*  See  Paper  by  Mr.  Pearson,  "  Medico-Ghir.  Trans./'  vol.  viii. 


406  SCIATICA,    AND   OTHER   FORMS    OF 

to  counterbalance  their  virtues ;  and  as  it  docs  not  appear 
from  the  recorded  cases  that  they  possess  a  curative  power 
superior  to  many  other  counter-irritants,  I  consider  that  their 
use  should  not  be  resorted  to  except  in  extreme  cases,  and 
when  other  remedies  have  failed. 

Various  other  external  applications  have  been  tried  for  the  re- 
lief of  this  painful  malady.  Thus  galvanism  and  electricity  have 
each  had  their  advocates,  and  by  some  have  been  lauded  as 
much  too  extravagantly  as  they  have  been  too  indiscriminately 
abused  by  others.  The  fact  appears  to  be,  that  when  the  dis- 
ease is  dependent  on  irritation  in  the  bowels,  or  is  sympathetic 
of  mischief  occurring  elsewhere,  they  exert  no  control  over  its 
progress,  and  usually  tend  to  aggravate  it,  if  used  before  the 
active  symptoms  have  subsided ;  whereas  when  the  complaint 
is  of  a  purely  neuralgic  nature,  and  is  unconnected  with  irrita- 
tion in  distant  parts  of  the  body,  the  continuous  galvanic  cur- 
rent is  often  of  essential  service,  and  speedily  mitigates  the 
patient's  sufferings.  In  all  cases,  as  soon  as  the  sensibility  of 
the  nerve  has  been  subdued,  and  while  the  patient's  limb  is 
weak  and  stiff  from  long-continued  inactivity,  electricity  supplies 
a  stimulus,  which  assists  materially  in  maintaining  the  nutrition 
of  the  muscles,  and  restoring  their  healthy  function.  But  if 
employed  before  the  pain  has  subsided,  the  interrupted  current 
very  generally  aggravates  the  patient's  sufferings. 

In  like  manner,  cold  has  found  eager  partisans,  who  have 
insiste<l  on  its  value  as  an  external  application,  especially  in 
the  form  of  ice.  I  cannot,  from  experience,  speak  favorably 
of  its  effects  when  so  applied,  inasmuch  as  it  has  failed  in 
almost  every  instance  in  which  I  have  seen  it  tried ;  but  possi- 
bly it  may  be  useful  in  those  cases  which  are  aggravated  by 
warmth,  and  accompanied  by  a  distressing  sense  of  local 
heat. 

Some  persons,  however,  protest  against  trusting  in  the 
moderately  benumbing  effect  of  ice,  and  recommend  the  appli- 
cation of  a  frigorific  mixture  to  the  part,  capable  of  reducing 
the  temperature  below  zero  of  Fahrenheit's  therm4)meter,  and 
producing  complete  anaesthesia.     The  proposer  and  chief  advo- 


NEURALGIC    RHEUMATISM.  407 

cate  of  this  plan  of  treatment  is  Dr.  James  Arnott,  who  has 
published  a  series  of  eases  successfully  combated  after  this 
method,  at  the  Brighton  Dispensary.*  The  frigorific  mixture 
employed  is  two  parts  of  finely-pounded  ice,  and  one  part  of 
common  salt,  and  this  application  usually  produces  complete 
anaesthesia  within  five  minutes.  "  If  the  mixture  be  properly 
prepared,"  he  says,  "the  moment  it  touches  the  part  it  be- 
numbs it ;  and  the  patient  is  hardly  sensible  of  the  application 
until  it  begins  to  produce  congelation.  It  is  seldom  spoken  of 
as  a  cold  application  ;  it  causes  a  slight  smarting  or  tingling, 
and  is  rather  warm  than  cold."  "  After  the  application,  when 
the  part  first  regains  its  sensibility,  there  is  a  similar  sensation 
of  smarting,  provided  means  be  not  adopted  to  prevent  it." 
But  the  mode  of  obviating  this  discomfort,  "  is  to  keep  the  heat 
of  the  part  for  some  time  under  its  natural  degree  ;  and  the 
application  of  a  bladder  containing  cold  water  is  the  best  mode 
of  effecting  this."^ 

In  cases  of  sciatica,  Dr.  Arnott  admits,  congelation  is  not  so 
striking  or  so  immediate  in  its  effects  as  in  lumbago,  "  which 
usually  yields  to  one  application  ;"  but,  he  says,  it  is  not  the 
less  successful,  though  more  than  one  application  may  be  re- 
quired. The  mischievous  reaction  which  is  found  to  follow 
the  employment  of  ice  as  a  benumbing  agent,  is  not  observed 
after  the  use  of  the  frigorific  mixture  of  ice  and  salt,  for  "the 
greater  energy  of  this  congelation  at  once  subdues  all  opposi- 
tion. It  permanently  depresses  the  vascular  and  nervous 
energies,  and  at  the  same  time  probably  modifies  the  local 
actions,"  and,  "although  sensibility  soon  returns  upon  the 
restoration  of  the  natural  temperature,  it  returns  in  its  natural 
or  normal  condition." 

My  own  experience  does  not  enable  me  to  pronounce  a  posi- 
tive opinion  upon  this  plan  of  treatment,  for  I  have  witnessed 
its  effects  in  only  three  instances.  In  one  case  the  frigorific 
mixture  was  had  recourse  to  during  the  acute  or  inflammatory 

1  "  On  Neuralgic,  Rheumatic,  and  other  painful  Affections,"  by  James  Ar- 
nott, M.D. 
^  Loc.  cit. 


408  SCIATICA,    AND    OTHER    FORMS    OF 

Stage  of  the  complaint,  and  the  pain  was  lulled  and  the  inflam- 
matory action  subdued.  The  patient,  however,  was  taking 
medicine  internally  at  the  same  time,  and  it  is  difficult,  there- 
fore, to  estimate  precisely  the  influence  exerted  by  the  external 
application.  In  the  other  two  cases,  which  were  instances  of 
chronic  painful  sciatica,  with  a  sense  of  heavy  weight  and 
numbness  of  the  limb,  following  an  acute  inflammatory  attack, 
the  mixture,  though  productive  of  momentary  relief — the  direct 
result  probably  of  anaesthesia — had  no  permanent  effect  on  the 
progress  of  the  disease.  Judging,  therefore,  from  what  I  have 
myself  witnessed,  as  also  from  the  known  effects  of  benumbing 
cold,  I  have  come  to  the  conclusion  that,  although  this  appli- 
cation may  possibly  be  useful  in  purely  painful  affections  of 
the  nerve,  in  cases  of  congestion  or  commencing  inflammation, 
and  in  those  cases  again  which,  whatever  their  cause,  are  ag- 
gravated by  warmth  and  accompanied  by  a  distressing  sense  of 
local  heat,  it  must  necessarily  fail  in  every  instance  in  which 
the  pain  arises  from  irritation  in  the  alimentary  canal  or  other 
distant  part,  or  in  which  inflammation  has  gone  on  to  effusion 
or  to  thickening  of  the  sheath  of  the  nerve ;  for  however  much 
cold  may  reduce  inflammation  and  deaden  pain  arising  from 
local  causes,  it  cannot  get  rid  of  the  fluid  poured  out  as  the 
product  of  inflammatory  action,  nor  can  it  subdue  pain  attribu- 
table to  the  persistent  agency  of  distant  causes.  The  instances, 
however,  cited  by  Dr.  Arnott,  seem  to  sIioav  that  the  powerful 
influence  of  this  agent  may  be  beneficially  employed  more 
frequently  than  might,  a  priori,  be  expected. 

Firm  and  continued  pressure,  as  with  a  ligature  or  the 
tourniquet,  is  another  expedient  which  has  been  adopted  for 
the  relief  of  the  agonizing  pain  in  certain  formidable  examples 
of  the  disease.  Applied  for  several  successive  hours,  it  is  said 
to  have  checked  the  violence  of  the  paroxysm,  and  to  have 
prevented  its  occurrence  in  intermittent  cases.  But  it  utterly 
failed  in  affording  relief  in  the  only  instance  in  which  I  have 
had  recourse  to  its  assistance,  and  I  am  unable,  therefore,  to  do 
more  than  record  the  fact  that  its  virtues  when  thus  employed 
have  been  highly  eulogized. 


NEURALGIC   RHEUMATISM.  409 

Terebinthinate  and  camphor  liniments,  and  various  stimulat- 
ing oils,  especially  the  oil  of  horse-chestnuts,  have  been  lauded 
as  components  of  antisciatica  embrocations,  and,  in  some  few 
instances,  have  been  productive  of  temporary  relief,  through 
their  agency  as  counter-irritants.  In  my  hands,  however, 
anodyne  applications  have  been  much  more  uniformly  success- 
ful. A  strip  of  flannel,  soaked  in  a  mixture  containing  equal 
parts  of  laudanum,  Hoffman's  sether,  and  glycerin,  to  every 
ounce  of  which  twenty  grains  of  the  extract  of  belladonna  have 
been  added,  placed  along  the  course  of  the  nerve,  and  then 
covered  with  oiled  silk  so  as  to  prevent  evaporation,  has  often 
been  the  means  of  mitigating  the  severity  of  a  paroxysm  in  a 
marvelously  short  space  of  time,  and,  in  some  few  instances, 
has  arrested  the  disease.  Chloroform,  employed  in  the  same 
manner,  has  also  proved  extremely  serviceable. 

Nothing,  however,  proves  more  generally  efficacious  than 
sulphur  applied  externally.  Whatever  its  mode  of  operation, 
the  fact  remains  that,  employed  in  this  manner,  it  often  sub- 
dues pain  which  has  persisted  in  spite  of  all  other  remedies.  In 
many  parts  of  England  the  sulphur  ointment  of  the  Pharmaco- 
poeia is  a  favorite  remedy  among  the  poor  for  the  cure  of  rheu- 
matism, whether  affecting  the  joints  or  other  parts  of  the  body, 
and  brief  notices  of  its  virtue  when  thus  employed  are  to  be 
found  sparsely  scattered  through  our  periodical  literature.  But 
in  no  recognized  treatise,  with  which  I  am  acquainted,  do  I  find 
the  slightest  notice  of  the  curative  action  of  sulphur  applied 
externally  ;^  and  I  am  indebted  to  one  of  my  hospital  patients 
for  directing  my  attention  to  the  subject.  He  was  a  man  forty- 
three  years  of  age,  who  had  been  afflicted  with  sciatica  in  a 
severe  form  above  five  months.  He  had  undergone  a  long 
course  of  medical  treatment  before  he  applied  at  the  hospital, 

1  Since  the  above  was  written,  my  attention  has  been  directed  by  Dr. 
Nicholson,  ofRedditch,  to  a  special  treatise  on  Sulphur  in  the  cure  of  rheuma- 
tism, published  by  Mr.  R  W.  Wallace,  so  long  ago  as  1820,  in  which  he  recom- 
mends local  sulphur  fumigation,  and  the  subsequent  wrapping  of  the  part  in 
flannel.  Moreover,  in  the  "  Lancet"  for  March  7,  1835,  vol.  i,  p.  810,  there  is 
an  interesting  notice  as  to  the  curative  effects  of  its  external  application,  by 
Mr.  George  Tucker. 
27 


410  SCIATICA,    AND    OTHER    FORMS    OF 

but  without  obtaining  the  least  mitigation  of  suffering,  and  I 
had  already  tried  several  remedies  with  little  success,  when  a 
friend  induced  him  to  put  sulphur  in  his  boots,  and  otherwise 
apply  the  remedy  externally.  In  four  days  he  was  much  re- 
lieved, and  in  less  than  a  fortnight  had  recovered  perfectly. 
Since  that  time  I  have  used  it  in  seventeen  chronic,  non- 
inflammatory cases  ;  and  in  six  only  did  it  fn\\  in  giving  relief. 
In  four  cases  the  relief  w^as  complete  and  permanent,  and 
occurred  within  ten  days  after  its  application  was  commenced  : 
in  three  others  considerable  alleviation  of  pain  w'as  obtained, 
but  a  complete  cure  was  not  effected,  and  in  the  remaining  four 
the  relief  was  only  partial  and  transient.  Several  of  these 
cases,  however,  occurred  among  my  out-patients  at  St.  George's 
Hospital,  and  it  is  questionable  whether  the  remedy  was  tried 
fairly  and  perseveringly. 

The  mode  in  Avhich  I  usually  employ  it  is  to  sprinkle  thickly 
with  precipitated  sulphur  a  piece  of  new  flannel,  in  which  the 
whole  of  the  affected  limb  is  to  be  incased,  from  the  foot  up- 
ward. This  should  be  kept  in  its  place  by  a  bandage,  and 
when  expense  is  not  of  importance,  the  whole  limb  so  bandaged 
should  be  covered  with  oiled  silk  or  gutta-percha,  which  has  the 
effect  not  only  of  increasing  the  warmth,  and  confining  the 
vapor  of  the  sulphur,  but  also  of  obviating  the  disagreeable 
odor  consequent  on  the  application  of  the  remedy.  This  band- 
age should  be  kept  applied  day  and  night.  Contrary  to  what 
might  be  expected  a  priori,  absorption  of  the  sulphur  takes 
place  rapidly,  and  the  breath,  the  urine,  the  secretions  from 
the  bowels,  and  the  cutaneous  exhalation  unmistakably  attest 
its  presence  in  the  system.  And  this,  probably,  explains  the 
mystery  of  its  action  in  mitigating  or  subduing  the  pain  of 
sciatica.  For  not  only  does  the  remedy  find  its  way  into  the 
circulation  as  readily,  if  not  more  so,  than  when  administered 
by  the  mouth,  but  it  is  applied  to  the  affected  part  more  directly, 
more  constantly,  and  in  larger  quantities  than  it  can  be  under 
any  other  mode  of  administration.  The  only  exception  to  this 
is  wiien  the  skin  is  dry  and  inactive,  in  which  case  the  sulphur 
does  not  disappear,  the  excretions  give  no  token  of  its  absorp- 


NEURALGIC    RHEUMATISM.  411 

tion  into  the  system,  and  the  remofly  fails  in  affording  relief, 
unless  means  are  taken  to  stimulate  cutaneous  action. 

Whatever  the  precise  influence  it  exerts  in  sciatica,  there 
cannot  be  a  doubt  that  its  beneficial  eflfects  are  most  strikingly 
displayed  in  chronic  cases  unattended  by  any  symptoms  of 
inflammation — in  cases  in  which  the  limb  feels  cold,  and  pain 
is  felt  only  on  exertion.  If  any  symptoms  of  inflammation  are 
present,  and  if  the  pain  is  excessive  even  when  the  limb  is  at 
rest,  then,  according  to  my  observation,  sulphur  is  seldom  of 
any  benefit,  and  in  some  instances  may  possibly  aggravate  the 
pain.  And  if  its  action  be  to  stimulate  the  capillary  circula- 
tion, as  has  been  suggested  by  Sunderlin  and  others  of  the 
German  school,  it  is  not  difficult  to  conceive  how  its  influence 
may  prove  beneficial  in  certain  instances,  and  no  less  prejudi- 
cial in  others. 

I  have  hitherto  made  no  mention  of  baths  as  curative  agents 
in  this  form  of  disease,  nor  is  it  necessary  to  do  more  than 
briefly  allude  to  them.  When  the  cause  of  the  disease  has 
passed  away,  and  only  pain  remains,  the  effect  of  former  mis- 
chief, baths,  if  not  wholly  inoperative  for  good,  are  at  all  events 
inadequate  to  eff*ect  a  cure.  So,  also,  when  the  pain  is  attribu- 
table to  gastric  or  intestinal  irritation,  baths,  if  serviceable, 
prove  so  by  promoting  free  cutaneous  action,  and  thus  improv- 
ing the  general  health,  more  than  by  any  direct  local  influence 
they  exert.  But  when  the  origin  of  the  mischief  is  rheumatic, 
and  the  blood  is  charged  with  the  morbific  element,  Avarm  baths, 
and  vapor  and  hot-air  baths,  may  be  as  useful  as  they  are  in 
other  forms  of  rheumatism.  In  some  chronic  cases,  shower 
baths  prove  excellent  tonics,  and  go  far  toward  eff"ecting  the 
eradication  of  the  disorder;  and  cold  bathing,  more  especially 
in  salt  water,  is  an  excellent  adjuvant  to  medicine,  in  impart- 
ing vigor  to  the  system,  and  enabling  it  to  throw  off"  the  rem- 
nants of  the  malady.  In  Russia  the  occasional  use  of  a  hot 
bath  or  a  vapor  bath,  immediately  followed  by  a  shower  bath, 
or  an  ordinary  water  bath,  cold  or  tepid,  according  to  circum- 
stances, has  a  great  repute  as  a  powerful  restorative  of  a  healthy 
cutaneous  circulation,  and  this,  together  with  certain  other  forms 


412  SCIATICA,    AND    OTHER    FORMS    OF 

of  rational  hydropathy,  in  which  strict  attention  to  the  daily 
routine  of  life,  rational  habits,  rational  diet,  rational  exercise, 
and  rational  repose,  play  an  important  part  in  the  restoration 
of  health,  will  often  enable  us  to  effect  a  cure,  even  when  our 
best-directed  efforts,  when  unassisted  by  these  potent  auxilia- 
ries, have  proved  quite  unavailing. 

But  if  vapor  and  other  artificial  baths  are  sometimes  of  ser- 
vice in  this  form  of  complaint,  much  more  so  are  the  natural 
mineral  waters.  The  springs  of  Bath,  Harrogate,  and  Buxton 
have  long  enjoyed  a  well  merited  reputation  for  the  cure  of 
certain  forms  of  this  malady,  and  many  of  the  Continental 
spas  are  resorted  to  for  the  same  purpose.  The  waters  of  Wood 
Hall,  in  Lincolnshire,  which  contain  iodine  and  bromine  in  large 
quantities,  are  rising  rapidly  in  estimation,  and  in  more  than 
one  instance  I  have  known  them  afford  relief  which  had  proved 
unattainable  by  other  means.  But  before  recommending  a 
patient  to  resort  to  any  particular  watering-place,  it  behooves 
us  to  consider  well  the  history  of  his  case,  the  precise  nature 
of  the  symptoms,  and  his  constitutional  peculiarities,  for  the 
various  waters  differ  so  greatly  in  their  action,  that  if  we  tail 
to  select  the  spring  adapted  to  his  particular  case,  he  will  prob- 
ably derive  little  benefit  from  their  operation. 

The  preceding  observations  apply  only  to  baths  in  which  the 
whole  body  is  immersed,  but  it  must  not  be  forgotten  that  local 
baths  of  various  descriptions  add  greatly  to  the  effect  of  other 
treatment,  particularly  when  the  complaint  is  of  rheumatic 
origin.  Even  in  the  acute  stage,  warm  fomentations,  constantly 
applied,  afford  much  ease  and  comfort ;  and  their  efficacy  may 
be  increased  by  the  addition  of  an  alkaline  and  opiate  solution, 
as  recommended  in  a  previous  chapter.  When  the  disease  has 
assumed  a  chronic  form,  douches  of  hot,  cold,  or  tepid  water, 
or  douches  of  vapor,  simple  or  medicated,  repeatedly  applied, 
are  often  of  the  greatest  service.  They  neither  distress  nor 
exhaust  the  patient,  but  they  stimulate  and  soothe  the  affected 
parts,  and  assist  in  the  re-establishment  of  their  healthy  func- 
tions. Indeed,  one  of  the  most  useful  local  applications  is  the 
vapor  douche  applied  to  a  part  which  has  been  smeared  or 


NEURALGIC    RHEUMATISM.  413 

painted  with  some  sedative  extract  or  tincture  mixed  with  gly- 
cerin. It  combines  the  influence  of  the  sedative  and  the  vapor 
douche  more  eflfectually,  I  believe,  than  does  the  application  of 
medicated  vapor. 

On  the  same  principle  on  which  shower  baths  have  been 
found  beneficial,  various  tonic  medicines,  such  as  quinia,  iron, 
zinc,  and  arsenic,  have  proved  serviceable  to  patients  of  broken 
health  or  weakly  constitution.  But  they  are  not  all  equally 
useful  in  every  case.  Quinia  appears  to  be  the  most  efficient  rem- 
edy, in  proportion  as  the  appetite  has  been  bad,  and  the  attacks 
more  or  less  distinctly  intermittent,  while  iron  proves  most  use- 
ful in  pallid  or  anaemic  persons  with  a  weak  pulse  and  a  feeble 
circulation  ;  and  zinc,  when  the  patient  is  of  an  irritable  con- 
stitution, and  the  attacks  are  characterized  by  much  spasmodic 
action.  Arsenic  is  most  serviceable  to  those  in  whom  the  attacks 
have  been  paroxysmal,  and  accompanied  by  symptoms  of  a  ner- 
vous character.  Seldom,  however,  will  either  of  these  medicines 
prove  really  efficient,  unless  preceded  by  the  administration  of 
remedies  directed  against  the  state  of  system  out  of  which  the 
primary  mischief  has  arisen.  If  the  attack  is  of  rheumatic 
origin,  alkalies,  colchicum,  and  anodynes  are  just  as  necessary 
as  in  the  more  active  forms  of  the  disease,  though,  of  course, 
in  doses  proportionate  to  the  severity  of  the  symptoms  ;  and 
so  are  vegetable  bitters  and  alteratives,  to  restore  a  healthy 
state  of  assimilation.  Without  the  previous  administration  of 
medicines  such  as  these,  to  subdue  present  irritation,  and  pro- 
vide against  the  further  generation  of  the  poison,  quinia  and 
arsenic  may  be  given  in  vain  ;  and,  in  like  manner,  anodynes 
with  colchicum,  and  other  antirheumatic  medicines,  may  be 
ineffectual  in  affording  permanent  relief,  unless  followed  by  a 
course  of  tonics. 

There  is  one  fact  in  regard  to  sciatica  and  other  forms  of 
neuralgic  rheumatism,  which  must  not  be  allowed  to  pass  with- 
out notice,  the  more  so  as  it  has  a  direct  practical  bearing  on 
the  treatment  of  many  forms  of  this  disease.  I  allude  to  the 
presence  of  a  large  quantity  of  oxalate  of  lime  in  the  urine. 
Case  after  case  has  come  under  my  notice,  in  which  iodide  of 


414  SCIATICA,    AND    OTHER    FORMS    OF 

potassium,  alkalies,  colcliicum,  guaiacum,  warm  baths,  embro- 
cations, and  other  expedients  have  been  fruitlessly  employed 
before  the  patient  came  under  my  care,  and  in  which  micro- 
scopical examination  of  the  urine  has  revealed  to  me  at  once 
the  class  of  remedies  necessary  to  relieve  the  patient's  suffer- 
ings. The  cases  in  which  oxaluria  occurs  are  usually  charac- 
terized by  nervous  irritability  and  languor,  rather  than  by  fever 
or  arterial  excitement,  and  the  urine  is  often  left  unexamined 
because  it  is  clear,  bright,  and  plentiful.  Viewed,  however,  in 
considerable  quantity,  it  will  usually  present  a  peculiar  green- 
ish tint,  and  if  it  be  allowed  to  remain  for  the  space  of  two  or 
three  hours,  in  a  funnel-shaped  glass,  the  deposit  which  occurs 
will  be  found  to  contain  the  octohedral  crystals  of  oxalate  of 
lime.  In  such  cases  the  internal  administration  of  nitromuriatic 
acid  in  full  doses,("ivi-x,)  aided  by  an  occasional  brisk  purgative, 
the  cold  shower  bath,  or  a  cold  douche  down  the  spine,  fol- 
lowed by  active  manual  friction,  proves  the  most  effectual,  I 
might  almost  say  the  only  effectual,  mode  of  getting  rid  of  the 
complaint.  In  no  case  of  disease  with  which  I  am  acquainted 
does  improvement  follow  more  rapidly  after  the  commencement 
of  treatment.  But  the  effects  of  the  treatment  are  most  strik- 
ing when  it  can  be  combined  with  change  of  air  and  scene. 
For  this  is  a  form  of  complaint  which  usually  occurs  in  persons 
who  lead  a  sedentary  life  and  are  closely  engaged  in  study  or 
some  other  active  mental  exercise;  and  perfect  relaxation  of 
mind  is  almost  as  useful  in  such  cases  as  the  most  potent  drugs 
of  our  Pharmacopoeia.  But  as  medicine,  without  due  rest  and 
mental  quietude,  is  of  less  avail  than  when  assisted  by  such 
auxiliaries,  so  change  of  scene  and  mental  recreation  rarely 
prove  effectual  in  removing  the  complaint  without  the  aid  of 
proper  remedies.  Therefore,  whenever  a  case  occurs  which 
presents  the  conditions  referred  to,  I  make  a  point  of  recom- 
mending change  of  air,  as  soon  as  I  have  satisfied  myself  that 
the  course  of  treatment  pursued  is  proving  beneficial  to  the  pa- 
tient. And  when  this  plan  is  adopted,  a  few  weeks'  attention 
to  the  general  health,  combined  with  judicious  medical  treat- 
ment, usually  succeeds  in  eradicating  the  disorder. 


NEURALGIC    RHEUMATISM.  415 

If  it  be  asked  how  nitromuriatic  acid  operates  in  getting  rid 
of  the  oxalate  of  lime,  and  with  it,  as  it  does,  of  the  nervous 
pains,  I  answer,  that  we  are  just  as  ignorant  of  the  matter  as 
on  the  first  day  when  chemistry  became  a  science.  But  to  those 
who  show  themselves  unwilling  to  accept  or  act  upon  an  ascer- 
tained fact  unless  it  can  be  supported  by  theory,  I  would  reply 
by  suggesting,  with  Dr.  Headland,^  that  the  action  of  nitro- 
muriatic acid  in  checking  the  tendency  to  oxaluria  may  be  by 
serving  as  an  oxidizing  agent,  and  favoring  the  conversion  of 
oxalic  acid  into  carbonic  acid.  Thus  : 
CA+0=2C02. 

Be  this  as  it  may,  the  important  practical  fact  remains,  that 
when  sciatica  is  accompanied  by  the  abnormal  condition  of  the 
urine  before  referred  to,  the  remedies  recommended  have  the 
effect  of  removing  that  condition,  and  with  it  the  wearing  pain 
down  the  sciatic  nerve. 

I  have  hitherto  spoken  only  of  affection  of  the  great  sciatic 
nerve,  because  it  affords  some  of  the  best  examples  of  this  par- 
ticular form  of  rheuioatism.  But  not  unfrequently  the  brachial 
and  the  facial  nerves  are  also  implicated,  and  there  are  some 
points  relating  to  their  affection  which  require  a  passing  notice. 
It  must  always  be  remembered  that  here,  as  in  sciatica,  the  com 
plaint  may  be  rheumatic,  or  may  be  referable  to  other  causes. 
It  may  have  arisen  from  long  exposure  to  cold  or  draughts,  or  it 
may  be  connected  Avith  agencies  of  a  totally  different  nature. 
The  pain  in  the  arm  may  be  sympathetic  of  mischief  in  the 
heart  or  in  the  brain  ;  and  the  pain  in  the  face,  of  disease  in  the 
antrum  ;  or  in  the  teeth  and  their  sockets,  of  disorder  of  the 
stomach  and  intestinal  canal,  or  of  the  irritation  connected  with 
a  gravid  uterus.  Many  persons  suffer  invariably  from  face- 
ache  or  toothache  during  pregnancy,  as  also  when  their  stomach 
or  bowels  are  out  of  order.  Therefore,  when  summoned  to  the 
relief  of  a  patient  suffering  from  either  of  these  forms  of  dis- 
ease, the  first  point  to  be  ascertained  is  that  the  disease  is 
really  what  it  appears  to  be,  a  primary  affection  of  the  nerves 

1  See  Headland  ■'  On  the  Action  of  .Medicines."  pp.  186-9. 


416  SCIATICA,    AND    OTHER    FORMS    OP 

and  tlieir  fibrous  sheaths,  and  not  pain  symptomatic  of  distant 
local  mischief.  This  being  determined,  the  same  general  plan 
of  treatment  should  be  pursued  as  has  been  already  recom- 
mended for  the  cure  of  sciatica.  When  the  affection  is  purely 
neuralgic,  quinia  in  full  doses  ;  the  sulphate  of  zinc,  pushed 
until  two  scruples  or  a  drachm  are  taken  daily ;  the  sesqui- 
carbonate  of  iron :  or  arsenic,  each  of  which  may  be  combined, 
if  necessary,  with  aconite,  and  aided  in  their  action  by  a  seda- 
tive at  night,  and  an  occasional  morning  laxative,  are  usually 
the  most  efficient  internal  remedies,  and  their  salutary  effects 
may  be  greatly  promoted  by  external  anodyne  applications. 
Those  already  mentioned  are  often  quite  effectual  for  the  relief 
of  the  pain,  but  when  they  fail,  chloroform  or  chloric  ether, 
applied  in  the  palm  of  the  hand  to  the  seat  of  pain,  sometimes 
exerts  a  magically  soothing  influence,  while  at  others  the  ex- 
ternal application  of  hydrocyanic  acid  is  attended  with  the  hap- 
piest results.'  When  the  bra-chial  nerve  is  the  part  at  fault, 
the  various  remedies  which  prove  useful  in  sciatica  may  be  tried 
with  a  reasonable  prospect  of  success,  but,  in  this  form  of  the 
complaint,  greater  benefit  is  derived  from  a  solution  of  aconi- 
tine,  or  from  the  use  of  the  aconitine  or  veratria  ointment,  than 
from  any  other  external  application. 

The  following  cases  will  serve  to  illustrate  some  of  the  points 
already  mentioned  relative  to  treatment. 

Case  I. — On  the  10th  of  January,  1853,  I  was  asked  to  see 

Colonel ,  aet.  57,  who  had  been  a  martyr  to  sciatica  in  the 

right  leg  nearly  ten  months.  There  was  no  gout  in  his  family, 
and  he  had  never  experienced  an  attack  either  of  gout  or  rheu- 
matism ;  but  some  years  ago,  while  in  South  America,  he  had 
intermittent  fever,  followed  by  violent  "tic"  in  the  face.  The 
pain  on  the  present  occasion  came  on  suddenly,  soon  after  a 
long  fatiguing  ride  in  a  cold  easterly  wind.  He  was  not  aware 
of  having  ricked  or  hurt  himself,  and  could  not  account  for  the 
invasion  of  the  disease.     Before  he  applied  to  me,  he  had  taken 

'  A  lotion  coniposecl  of  half  an  ounce  of  Pharmacopoeia  acid,  in  combination 
with  two  drachms  of  rose-water,  and  two  drachms  of  glycerin,  painted  on  the 
seat  of  pain  by  means  of  a  camel's-hair  brush,  is  an  application  which  I  have 
often  found  useful. 


NEURALGIC    RHEUMATISM.  417 

alkalies,  colchicum,  iodide  of  potassium,  sulphur,  guaiacum, 
and  various  other  internal  remedies ;  had  applied  blisters  and 
embrocations  to  the  leg,  and  had  been  to  Bath  and  Aix-la- 
Chapclle  without  relief. 

When  I  first  saw  him,  he  was  thin  and  sallow,  and  was  look- 
ing much  worn  in  consequence  of  long-continued  want  of  rest. 
He  described  the  pain  as  being  ordinarily  of  a  dull,  aching 
character ;  but  it  was  aggravated  in  paroxysms,  which  gen- 
erally occurred  about  twice  a  week,  and  often  lasted  several 
hours,  during  which  the  whole  limb  quivered  with  pain.  He 
was  easy  while  lying  quiet,  but  the  least  attempt  at  motion 
invariably  induced  acute  pain  in  the  hip,  thigh,  and  leg.  The 
acts  of  coughing,  sneezing,  or  laughing  were  also  productive 
of  an  attack.  His  tongue  was  clean  and  moist ;  bowels  usually 
regular ;  urine  clear,  but  containing  an  unusual  quantity  of 
oxalate  of  lime  crystals ;  pulse  84,  soft. 

As  his  history  and  present  symptoms  seemed  to  negative  the 
idea  of  his  being  truly  rheumatic,  and  appeared  to  point  to 
neuralgia,  connected  probably  with  some  obscure  miasmatic 
influence,  as  the  cause  of  his  suffering,  I  prescribed  the  follow- 
ing remedies,  viz.  : 

Tincturae  Aconiti,  T)\vj; 
Quinae  Disulphiitis,  gr.  iv  ; 
Acidi  Sulphuric!  Diluti,  5ss  ; 
Syrupi,  5iss  ; 
Decocti  Uiuclionse,  5x. 
M.  ft.  Haustus  ter  die  sumendus. 

Extracti  Beliadonnfe,  gr.  j ; 
Pil.   Saponis   Comp.,  gr.   viij. 
M.  ft.  Pilulse  duaj  omni  nocte  suiuendse. 

Liquoris  Opii  Sedativi,  5vi ; 
Extracti  Belladonna^,  51 ; 
Tincturae  Aconiti,  3^  ; 
Glj'cerini,  ^'w. 

M.  ft.  Lotio  parti  affectae  more  exposito  applicanda. 

A  piece  of  lint  wetted  with  the  above  lotion,  and  covered 

with  oiled  silk,  was  applied  along  the  course  of  the  sciatic 

nerve ;   and  the  bowels  were  regulated  by  means  of  castor  oil 

and  an  occasional  enema  of  warm  water.     As  the  digestive 


418  SCIATICA,    AND    OTHER    FORMS    OF 

organs  were  not  out  of  order,  a  generous  diet  was  allowed.  At 
the  expiration  of  three  days  the  pain  was  much  easier;  he  was 
able  to  sleep  several  hours  uninterruptedly  during  the  night, 
and  could  walk  across  the  room  by  the  aid  of  a  stick,  without 
inducing  any  increase  of  suffering.  On  the  19th  the  pain  had 
so  far  subsided,  that  I  deemed  it  expedient  to  omit  the  pill  at 
night,  and  to  trust  exclusively  to  the  effect  of  the  mixture  and 
the  sedative  lotion.  The  omission  did  not  prevent  his  sleep- 
ing ;  on  the  contrary,  he  slept  well,  and  felt  more  comfortable 
next  day.  Indeed,  his  progress  toward  recovery  was  steady 
and  rapid.  On  the  25th  the  lotion  was  omitted,  and  the  mix- 
ture was  ordered  to  be  taken  only  twice  a  day.  On  the  30th  a 
simple  quinine  draught,  with  half  a  drachm  of  sulphate  of  mag- 
nesia, was  substituted  for  the  bark  and  aconite ;  and  on  the 
8th  of  February,  or  within  a  month  from  the  commencement 
of  treatment,  he  felt  perfectly  well,  and  all  medicines  were 
omitted. 


Case  II. — Elizabeth  Beasley,  aet.  46,  was  admitted  into  the 
Holland  AVard  of  St.  George's  Hospital  on  the  .1st  of  February, 
1853,  suffering  from  acute  sciatica  affecting  both  legs.  The 
attack,  which  came  on  suddenly  a  week  before  her  admission 
into  the  hospital,  had  been  preceded  for  six  days  by  wandering 
pains  in  the  limbs,  without  redness  or  swelling  of  the  joints, 
and  had  been  accompanied  from  the  first  by  cramps  and  start- 
ings  of  the  limbs.  She  had  never  before  experienced  an 
attack. 

On  admission,  the  pain  was  of  the  most  agonizing  description. 
Commencing  in  the  lower  part  of  the  back,  it  shot  through 
both  hips,  and  down  the  back  of  both  legs  as  far  as  the  ankles, 
giving  rise,  at  brief  intervals,  to  violent  cramp  and  starting  of 
the  limb,  with  an  aggravation  of  her  previous  suffering.  The 
act  of  coughing  or  sneezing,  and  the  least  attempt  at  motion  in 
bed,  induced  a  paroxysm  of  this  description  ;  and  so  also  did 
pressure,  however  slight,  in  the  course  of  the  nerve.  She  was 
utterly  unable  to  sleep  ;  her  countenance  was  anxious,  and  por- 


NEURALGIC    RHEUMATISM.  419 

trayed  the  agony  she  was  enduring ;  the  face  was  flushed ;  her 
skin  was  hot,  and  bathed  in  perspiration  ;  tongue  exceedingly 
furred ;  bowels  open ;  urine  scanty,  high  colored,  and  loaded 
with  lithates.     Pulse  120.     Catamenia  regular. 

As  the  history  of  the  case  afforded  evidence  of  the  existence 
of  rheumatism,  it  seemed  probable  that  the  extreme  violence  of 
the  pain  might  be  attributable  to  rheumatic  inflammation  of 
the  sheath  of  the  nerve  ;  and  I  was,  therefore,  induced  not  only 
to  administer  alkalies  and  other  antirheumatic  medicines,  but 
to  have  recourse  to  calomel  and  opium.  The  following  is  the 
form  in  which  the  remedies  were  prescribed  : 

Hydrargyri  Chloridi,  gr.  iij  ; 
Opii,  gr.  i. 
M.  ft.  Pilula  ter  die  sumeada. 

Haustus  Senna;  eras  mane. 
Potassii  lodidi,  gr.  v; 
Vini  Colehici,  Tt\xx  ; 
Potassae  Bicarbonatis, 
Potassae  Acetatis,  aa  3ij  ; 
Haustus  Potassae  Citratis,  ^iss. 
M.  ft.  Haustus  Gta  quaque  hora  sumendus. 
Broth  diet. 

On  the  5th,  the  urine  had  become  clear,  and  had  increased 
in  quantity,  the  violent  cramps  and  startings  of  the  limbs  had 
ceased,  and  the  pain  was  easier.  She  complained,  however,  of 
a  sense  of  weight  and  numbness  of  the  affected  limb  which  she 
had  not  before  experienced.  The  remedies  were  continued  as 
before.  On  the  8th.  there  was  still  further  improvement,  and 
the  pill  was  ordered  to  be  taken  only  twice  a  day.  On  the 
10th,  as  the  improvement  continued,  it  was  given  only  once 
daily.  On  the  12th,  there  was  no  longer  any  numbness  or 
sense  of  increased  weight  in  the  limb,  and  therefore  the  pill 
was  discontinued.  On  the  18th,  as  little  or  no  pain  remained, 
and  she  was  somewhat  weak,  it  was  determined  to  omit  the 
draught,  administer  bark,  combined,  by  way  of  precaution, 
with  liquor  potassae  and  iodide  of  potassium.  This  she  con- 
tinued to  take  until  March  2d,  when,  as  there  was  no  return  of 
pain,  and  she  felt  quite  strong,  she  was  permitted  to  return 
home. 


420  SCIATICA,    AND    OTHER    FORMS    OF 

Case  III. — Thomas  Lloyd,  set.  29,  was  admitted  into  the 
York  Ward  of  St.  George's  Hospital  on  April  8th,  1857.  A 
clerk  by  occupation,  he  had  not  been  exposed  to  any  external 
agencies  likely  to  produce  an  attack  of  sciatica,  but  he  had 
been  "  out  of  sorts"  for  some  months,  and  latterly  had  expe- 
rienced wandering  rheumatic  pains.  On  the  28th  of  March, 
he  had  been  seized  with  shivering,  followed  by  pain  shooting 
down  the  back  of  both  thighs  and  legs  as  far  as  the  ankles,  and, 
in  spite  of  treatment,  this  had  gradually  increased  up  to  the 
date  of  his  admission. 

When  I  first  saw  him.  he  was  suffering  acutely  from  sciatica 
in  both  legs,  especially  the  right.  The  pain  was  excruciating, 
even  when  he  was  at  rest,  and  any  attempt  at  motion  gave  rise 
to  involuntary  starting  of  the  limb,  and  occasionally  to  cramp 
in  the  muscles  of  the  calf.  His  skin  Avns  hot  and  perspiring; 
tongue  coated  and  white  :  saliva  acid  ;  bowels  reported  regular  ; 
urine  scanty,  turbid,  and  acid.     Pulse  96,  small  and  irritable. 

As  the  history  of  the  case  pointed  clearly  to  true  rheuma- 
tism as  the  cause  of  the  seizure,  I  determined  to  administer 
alkaline  remedies  in  the  following  manner,  viz. : 

PotassjE  Acetatis, 
Potasste  Bicarboiiatis,  aa  3ij  ; 
Misturas  Guaiaci.  ^iss. 
M.  ft.  Haustus  ter  die  sumendns. 

At  the  same  time,  with  the  view  of  testing  the  efiicacy  of 
sulphur  externally,  I  had  it  applied  to  the  right  leg  only,  in  the 
manner  recommended  at  page  410  of  this  treatise.  His  diet 
was  restricted  to  beef  tea. 

By  the  11th,  the  pain  was  easier  in  the  left  leg,  and  he  had 
lost  all  pain  in  the  right  leg,  to  which  th?  sulphur  had  been  ap- 
-plied.  The  tongue  had  become  clean  ;  the  bowels  were  acting 
regularly  ;  and  the  urine  was  clear,  but  still  acid.  The  medi- 
cine was  continued  as  before,  but  he  was  allowed  fish  for  dinner. 

On  the  15th,  he  no  longer  complained  of  pain,  and  asked 
leave  to  get  up  and  dress.  This  was  permitted,  and  he  was 
ordered  "ordinary  diet,"  and  to  take  the  medicine  only  twice 
a  day. 


NEURALGIC    RHEUMATISM.  421 

On  the  19tli,  slight  rheumatic  swelling-  of  the  ankles  took 
place,  but  there  was  no  recurrence  of  sciatica.  The  diet  was 
changed  again  to  fish  and  beef  tea,  and  the  medicine  was  con- 
tinued. 

On  the  23d,  the  swelling  of  the  ankles  had  disappeared,  and 
it  was  judged  safe  to  recur  to  ordinary  diet.  From  this  time 
he  gained  strength  daily  :  he  had  no  recurrence  of  rheumatism 
or  sciatica,  and  was  therefore  permitted  to  leave  the  hospital 
on  the  SOth. 


Case  IV. — John  Collins,  set.^S,  was  admitted  into  the 
King's  Ward  of  St.  George's  Hospital  on  December  16th, 
1857,  suffering  from  sciatica  of  the  left  side.  The  attack 
commenced  ten  weeks  previously,  coincidently  with  pain  and 
swelling  of  the  left  foot  and  knee,  and  of  both  hands.  The 
swelling  of  the  joints  soon  subsided  under  treatment,  but  the 
sciatica  had  continued  unabated.  During  the  firf-t  violence  of 
the  attack,  he  had  sweated  profusely. 

On  admission,  his  complexion  was  pale  and  sallow  ;  the  skin 
cool ;  tongue  coated  ;  bowels  very  costive  ;  pulse  84,  w'eak  ; 
urine  clear,  but  acid.  Appetite  good.  The  pain  down  the 
sciatic  nerve  was  of  a  dull,  wearing  character,  and  did  not 
amount  to  acute  suffering,  except  when  he  attempted  to  sit  or 
stand.  His  easy  posture  was  lying  on  his  back  in  bed,  with 
the  knee  slightly  flexed.  There  was  not  any  tenderness  of  the 
nerve  on  pressure. 

As  the  symptoms  manifestly  originated  in  true  rheumatism, 
and  their  persistence  was  probably  connected  wdth  irritation  of 
the  sacral  plexus  of  nerves  consequent  on  long-continued  con- 
stipation, the  following  medicines  were  prescribed,  viz. : 

Olei  Tiglii,  ir^i ; 

Pilulae  Colocynth.  c.  (Jalomelanae,  gr.  v. 
M.  ft.  Pilula  statim  sumenda. 

Pulveris  Guaiaci, 
Sulphuris  Loti, 
MagnesiiB  Carbonatis, 
Sodae  Bicarbonatis,  aa  S^s. 
M.  ft.  Pulvis  tei-  die  suraendus. 


422  SCIATICA,    AND    OTHER    FORMS    OF 

Tlie  bezels  acted  freely  during  the  ITtli  and  18th,  and  on  the 
following  day  the  pain  down  the  sciatic  nerve  had  ceased,  and 
his  water  was  slightly  alkaline.  I  therefore  ordered  the  powder 
to  be  repeated  every  morning  only,  and  prescribed  : 

Haustus  Cinchona^,  ^iss  ;  ter  die. 

From  this  time  he  progressed  favorably ;  there  was  no  re- 
turn of  pain  ;  and  he  left  the  hospital  on  the  25th. 


Case  V. — Georgiana  King,  get.  58,  was  admitted  into  the 
Queen's  Ward  at  St.  George's  Hospital  on  May  5th,  1858, 
suiferino;  from  sciatica  of  the  left  side,  of  four  months'  duration. 
The  pain,  which  was  severe,  had  not  intermitted  in  the  slightest 
degree  since  the  commencement  of  the  attack  ;  it  was  aggra- 
vated by  motion,  and  w^as  accompanied  by  occasional  cramp  and 
starting  of  the  leg.  She  had  not  experienced  pain  in  other 
parts  of  the  body  during  present  illness,  neither  had  she  been 
previously  subject  to  rheumatism,  and  she  had  never  before 
undergone  an  attack  of  sciatica.  Blisters  and  liniments  had 
been  applied  externally,  and  various  internal  remedies  had 
been  administered  during  the  two  months  preceding  her  admis- 
sion to  St.  George's  Hospital,  but  nothing  had  afforded  the 
sliw-htest  relief. 

On  admission,  the  aspect  was  healthy;  the  skin  warm; 
tongue  clean  and  moist;  bowels  costive;  urine  clear  and  light 
colored,  and  free  from  crystals  of  oxalate  of  lime.  Pulse  108, 
irrita))lc,  and  rather  weak.  The  appetite  was  good.  The 
catamcnia  had  been  absent  since  the  age  of  thirty-four.  The 
p;iin  extended  from  the  left  hip  down  to  the  ankle  ;  but  no 
specially  tender  spot  could  be  discovered  in  the  course  of  the 
nerve. 

As  the  bowels  were  confined,  and  as  the  condition  of  the 
urine  seemed  to  point  to  neuralgia  rather  than  to  true  rheuma- 
tism, as  the  cause  of  the  pain,  I  ordered  a  large  turpentine 
enema  to  be  administered  at  once,  with  the  view  of  thoroughly 


NEURALGIC    KHEUMATISM.  423 

emptying  the  lower  bowel ;  and  prescribed  the  following  draught, 

viz. : 

Tincturje  Aconiti,  Ti|vj ; 
H.iustus  Cinchome,  ^is3. 
M.  ft.  Hanstus  sextis  horis  sumendus. 

At  the  same  time,  as  her  tongue  was  clean,  and  her  digestive 
organs  appeared  to  be  in  good  order,  I  gave  her  the  ordinary 
diet  of  the  hospital. 

On  the  7th,  as  the  bowels  had  not  acted  freely,  it  was 
judged  expedient  to  administer  ten  grains  of  colocynth  and 
calomel. 

The  pills  were  repeated  on  the  Jrlth,  and  again  on  the  14th  ; 
but,  with  this  exception,  no  alteration  was  made  in  the  treat- 
ment throughout  the  period  of  her  residence  in  the  hospital.  From 
the  first,  it  was  manifest  that  the  medicine  was  exercising  a 
beneficial  influence,  for  the  severity  of  the  pain  subsided  within 
a  few  days.  On  the  18th  all  pain  had  ceased  ;  and  on  the  19th 
she  was  permitted  to  leave  the  hospital. 


Case  VI. — Henry  South,  a  laborer,  set.  29,  was  admitted 
into  the  King's  Ward  of  St.  George's  Hospital,  on  the  29th  of 
September,  1858,  suffering  from  sciatica  of  the  left  side.  The 
pain,  which  was  of  six  months'  duration,  extended  from  the  hip 
down  the  thigh  and  leg.  It  was  of  a  dull,  wearing  character, 
but  was  much  increased  by  motion,  and  by  every  act  of  strain- 
ing, as  in  coughing,  sneezing,  and  the  like.  For  some  length 
of  time  he  had  not  had  a  good  night's  rest;  but  his  bowels  were 
regular,  and  the  various  bodily  functions  were  regularly  per- 
formed. Warm  baths,  galvanism,  and  various  internal  remedies 
were  had  recourse  to,  without  relief ;  and  on  the  30th  of  Octo- 
ber, as  no  benefit  had  resulted,  all  medicines  were  omitted. 

On  the  od  of  November,  Mr.  Charles  Hunter,  who  was  then 
house  surgeon,  introduced  a  finely-perforated  needle  into  the 
cellular  tissue  at  the  lower  border  of  the  left  buttock,  and  in- 
jected three-quarters   of  a  grain   of  the  acetate   of  morphia. 


424 


SCIATICA,    NEURALGIA,    ETC. 


Within  a  few  minutes  the  patient  became  drowsy  ;  and  at  the 
expiration  of  three-quarters  of  an  hour  he  fell  asleep.  The 
next  morning,  his  tongue  was  rather  dry,  and  he  vomited  once; 
but  his  pain  was  easier,  and  he  said  he  had  passed  a  quieter 
night  than  he  had  done  for  some  months.  In  the  evening  of 
the  4th,  the  injection  was  repeated,  the  solution  being  intro- 
duced into  the  cellular  tissue  of  the  right  arm.  He  went  to 
sleep  immediately  the  operation  was  concluded,  and  slept 
soundly  for  five  hours.  When  he  awoke,  he  had  less  pain  than 
on  the  previous  day.  From  this  time  his  progress  toward  re- 
covery was  steady  and  rapid.  Each  "night  the  injection  was 
repeated,  and  day  by  day  tBe  pain  decreased.  In  short,  five 
injections  were  found  sufficient  to  subdue  the  pain ;  and  he  left 
the  hospital  on  the  10th,  free  from  uneasiness,  and  able  to.walk 
comfortably.  No  sickness  or  discomfort  was  produced,  except 
after  the  first  injection. 


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